Environmental Health in Nigeria and the way forward

By Abiodun  Peter Bamigboye [Now late]

Introduction

Environmental factors play an important role in health and disease among the population of particular concern are young children and other high risk population group. Scientists have long worked to understand the environmental and humanity’s place in it. The search for this knowledge grows in importance as rapid increase in human populations and economic development intensify the stresses human beings place on the biosphere and ecosystems. People want to be warned of major environmental changes and, if the environment is under threat, want to know how to respond. Fortunately, rapid increases in scientific capability-such as recent advances in computing power and molecular biology and new techniques for sensing biological, physical, and chemical phenomena below, on, and above the Earth’s surface – together with the rediscovery that the human-environment relationship is a critical topic for the human sciences, are making it possible for science to provide much of this knowledge. The scientific excitement and challenge of understanding the complex environmental systems humans depend on, making the environmental sciences centrally important as humankind attempts a transition to a more sustainable relationship with the Earth and its natural resources.

The influence of the environment on health are varied and complex. Diarrhea, caused by unsafe water, inadequate sanitation and poor hygiene, accounts for 15 to 18 percent of child deaths annually. Malaria is responsible for 2.5 million deaths each year, mostly among young children. Acute lower respiratory infections (ART), mainly pneumonia – which has been closely associated with exposure to indoor smoke from cooking with biomass fuels, are the leading cause of death for children under five years of age.

A great deal of the underlying causes of disease, injury, and death in developing countries lie beyond the purview of the health care system. They cover a range of physical factors (inadequate sanitation, water, drainage, waste removal, housing, and household energy) and behavioral factors (personal hygiene, sexual behavior, driving habits, alcoholism, and tobacco smoking). Many of these environment- and occupation-related health problems turn into public health problems when they become widespread, a factor aggravated by inadequate public health infrastructure. Yet, policies in the sectors responsible for these negative health impacts are often not based on health criteria. The health sector itself tends to focus its interventions within the health care delivery system, not necessarily in other sectors that are the source of the problem^2,3. Similarly naturally occurring ecological factors that can exert negative impacts on all sectors (mosquito-borne diseases, arsenic in the water, floods, droughts, and so on) are seldom addressed systematically by any of the sectors at risk, even though some sectors may be exacerbating their effects (spreading mosquito habitats, consuming great quantities of water, or producing greenhouse gases that may worsen climate change). As a result, the enormity of health benefits possible through interventions outside the health sector is not being tapped. Environmental Health interventions are one of the important of those neglected areas.

The subject of Environmental Health (EH) is undoubtedly one that has generated a lot of debates both locally and internationally. It is a sector or sub-sector that is largely talked about but receiving little or no attention in many places particularly in developing countries of the world. The WHO’s concept of health brought in focus the ecological as well as the sociological paradigms of health with a view to holistically addressing issues relating to health and wellbeing. If health is seen not just as the absence of disease but also as a central goal of human development, then the protection of the environment and the protection and improvement of health are mutually supportive. It is against this background of increasing international focus on environmental sanitation, that the Committee on Environmental Sanitation was established by the first World Health Assembly in l948. The Committee’s first, groundbreaking report, published in 1949, concluded that physical development, health and survival, depended on the management of environmental factors which included excreta and community waste disposal; safe drinking water; food safety; healthy personal habits; understanding the causes of diseases; and, the control of disease vectors. It was decided to focus action on the reduction of infectious diseases by monitoring how they respond to environmental management, and that the lessons learned in public health engineering from the sanitary revolution in Europe and the Americas would be of particular value. Changes from old patterns of life were an essential precondition for the achievement of better environmental health. The historical account of the contribution of EH in 19th and 20th Century United Kingdom in ensuring good health and its adoption by the WHO as a fundamental approach to addressing global health situation underscores the relevance of this sub-sector.

During the 1 990s, a series of reports from think tank agencies, the World Health Organization (WHO), and the Centers for Disease Control and Prevention (CDC) rated environmental concerns among the most important health issues and global threats. They also ranked environmental public health and sanitation accomplishments among public health’s greatest accomplishments. The 30-year increase in life expectancy to 76.7 years from 1900 to 1998 has been attributed to environmental public health monitoring and regulation of the water supply, sewage systems, and food quality, as well as to immunizations and primary preventive care. As a result of proper sanitation, more than 80% of human disease has been eliminated The strong tradition of environmental public health and sanitary services was maintained through the middle 1 960s, when new environmental problems gathered attention: globalization of the food supply; contamination of drinking water; air and noise pollution; ionizing radiation; proliferation of solid and hazardous waste, disease vectors, and wastewater; and degradation of housing, institutional services, and environmental conditions in child-care facilities.

What is EH?

Environmental Health has been defined as the science which study the biological, chemical or physical agents introduced into the environment or occurring naturally and their effects on human health and ecological systems. The field also includes the study of human activities, a vital component in our complex ecosystem 6 (UGA, 2005). In another sense, ER is understood as the science of controlling or modifying those conditions, influences, or forces surrounding man which relate to promoting, establishing, and maintaining health. Toxicology and occupational health are also included in this category.

Environmental health as used by the WHO Regional Office for Europe, includes both the direct pathological effects of chemicals, radiation and some biological agents, and the effects (often indirect) on health and wellbeing of the broad physical, psychological, social and aesthetic environment which includes housing, urban development, land use and transport. In general term, EH comprises those aspects of human health, including quality of life, that are determined by physical, chemical, biological, social, and psychosocial factors in the environment. It also refers to the theory and practice of assessing, correcting, controlling, and preventing those factors in the environment that can potentially affect adversely the health of present and future generations. It would be seen from the foregoing that the scope of this field is wide and varied. These areas in which EH should focus include but may not be limited to those in table 1 below.

Table 1: Typical Responsibilities of Environmental Health and Protection Programs

• Ambient air quality
• Indoor air quality
• Water pollution control
• Safe drinking water
• Noise pollution
• Radiation
• Food safety
• Industrial hygiene
• Childhood lead poisoning
• Acid deposition
• Disaster planning and response
• Cross-connection elimination
• Healthy housing
• Institutional environmental control
• Recreational area environmental control
• Solid waste management
• Vector control
• Pesticide control
• Toxic chemical control
• On-site liquid waste disposal
• Unintentional injury control
• Bioterrorism
• Global environmental issues.

These services are provided by various cadres of trained personnel generally referred to as environmental health personnel who serve the general welfare by safeguarding and improving the quality of food, shelter, air, water and other natural resources. The role of EH in health and disease cannot be underestimated. One is quick to refer to the great sanitary reforms which follows the historic cholera outbreak in UK and the various feat achieved in the control and/eradication of some other diseases. The contributions of EH to the global burden of disease is also very significant (see table 2 below).

Table 2: Environmental Factors and the Global Burden of Disease: Proportion of Global DALYs Associated with Environmental Exposures (1990)

Diseases	Global DALYs 1000)	% attributable to envtal. factors	Envtal DALYs (1000)	% of all DALYs (all age group)
ARI	116,696	60	70,017	5.0
Diarrheal diseases	99,631	90	89,670	6.5
Vaccine preventable infections	71,173	10	9,117	0.5
T.B	38,426	10	3,843	0.3
Malaria	31,706	90	28,535	2.1
Injuries Unintended	152,188	30	45,656
Intended	56,459	NE*	NE	3.3
Mental health	144,950	10	14,495	1.1
Cardio vascular disease	133,236	10	13,324	1.0
Cancer	70,513	25	17,628	1.3
Chronic respiratory diseases	60,370	50	30,189	2.2
Total these diseases	975,350	33	320,470	23.0
Other diseases	403,858	NE	NE
Total all diseases	1,379,238	23	320,470

Source: WHO (1999). NE-Not Estimated

Failure to address peculiar EH problems has very grievous and economic implications with serious development implications. For instance, it is one record that the global neglect of EH sub-sector has the following development implications:

• 2.4 billion people lack access to basic sanitation
• 2 million people die every year from diarrheal diseases (including cholera) associated with inadequate water supply, sanitation and hygiene
• The majority are children in developing countries
• Water, hygiene and sanitation interventions reduce diarrhea incidence by 26% and mortality by 65%
• 200 million people, in 74 countries, are infected with schistosomiasis and soil-transmitted helminthes and 20 million suffer severe consequences
• Basic sanitation reduces schistosomiasis by up to 77%
• 500 million people are at risk from trachoma and 146 million are threatened by blindness
• Trachoma can be prevented by improving sanitary conditions and hygiene practices.

The need to reverse this ugly trend became necessary globally and WHO had many years ago realized this necessity. To spearhead these changes WHO was asked to develop/refine international sanitary standards and guidelines for national health services to involve them in priority environmental health programs, and to educate the public. Specifically the organization undertook to:

• Link environmental sanitation with other health-related activities
• Cooperate with other UN bodies
• Undertake demonstration projects, especially for rural sanitation
• Promote research and disseminate information
• Cooperate with governments in strengthening national health services in environmental matters, and develop human resources.

Since its inception in 1948, WHO has had to define how it would pursue the achievement of “The improvement of EH as called for in Article 2(1) of the Constitution. “The First World Health Assembly gave environmental sanitation the same priority as malaria, maternal and child health, tuberculosis, veneral diseases and nutrition and these priorities became known as ‘the big six’. It is a known fact that while some most developed countries have accorded such priority to EH, many of the countries in the South had not.

WHO has always maintained that EH and particularly sanitation is literally the foundation on which a sound public health structure must be built. The organization has also maintained that over 75% of all communicable diseases affecting humans are environmentally related. Over the last 50 years WHO has generated, evaluated and Shared new knowledge on safe disposal of excreta, sewage and community waste and has also been at the forefront of exploring the linkages between environmental pollution and change, and people’s health and livelihoods. There is no doubt that people, especially poor people living in countries where basic infrastructure is lacking, are seriously affected by environmental degradation. In addition, the ongoing and deteriorating situation of sewage causing environmental pollution needs urgent and serious attention.

The Millennium Development Goals (MDGs), adopted at the Millennium Summit of the United Nations in September 2000, call for a dramatic reduction in poverty and marked improvement in health h of t he poor. Access to safe water and sanitation is fundamental for better health, poverty alleviation and development; and improving water and sanitation services has been recognized as a crucially important strategy towards meeting the MDGs . Such an achievement is feasible, but given the scale of the problem, especially for sanitation facilities, far from assured.

Experience shows that while the importance of sanitation is recognized, progress is lagging far behind compared to the provision of safe water. The toll on human health is high, resulting in about 2 million deaths per year from diarrheal diseases and approximately 2 billion people infected with schistosommiasis and soil-transmitted helminth infections globally. A host of other diseases are related to poor disposal of human excreta, poorly constructed or managed latrines, and poor solid waste management and drainage. If the toll on human health and human life of all of these sanitation-related conditions could be effectively added up, it would truly reveal a tragedy of grave proportions. Therefore something has to he done.

The Challenges EH

Efforts at improving El-I services must address specific problems and challenges so as to accelerate service delivery for greater effectiveness. Globally, EH challenges operate within the context of the following issues

• Increasing urbanization

• Ageing physical infrastructure coupled with lack of preventive maintenance

• Sharpening inequalities, polarization of society and choices

• Decaying family and community fabric

• An ageing population

• Increasing stress

• Centralization of decision making and power – but local nationalism

• Extremism/fundamentalism/terrorism

• Environmental degradation

• Diminishing natural resources

• Need for sustainable environments and sustainable lifestyles

These challenges are also manifesting in an environment whereby specific issues likely to hinder effectiveness arc apparent. These constitute serious threat to El I services in many places in the world. As a matter of fact, predictions for specific future of EH services should bear in mind:

• Emerging & re-emerging pathogens

• Resistant and virulent strains

• Bio-terrorism

• Global warming – related health problems & natural disasters

• Population movements

• Water shortages. & related conflicts

• Energy shortages

• Infrastructure failures

• Social polarization

• Globalization of markets and products

• Greater awareness of Genetic susceptibility of individuals and groups

• Improved toxicological techniques

• Better informed public; class actions

In Nigeria, efforts directed at improving EH services are challenged by the following factors:

1. Weak Governmental policy and legislations.

Many people had argued that policies are non-existent but the fact is that no nation exists without one form of policy or the other. Policies directed towards improving EH services in Nigeria are weak and ineffective. There also seem to be some constitutional defects in the role definition as regards responsibility for ER matters. While it is generally believed that ER services are largely the responsibility of LGAs. It is a known fact that LGAs as presently constituted, financed and managed would be unable to ensure a healthy environment. The need for a reappraisal may be necessary. The National Policy of Environmental Sanitation championed by the Federal Ministry of Environment is a right step towards addressing this problem. However, its implementation must be devoid of sentiments, and unnecessary bureaucracies.

In addition to this is the fact that most EN legislations are either obsolete, inconsistent or had failed to take cognisance of the cultural settings in which they are supposed to operate. The need for suitable legislations to address specific EH issues is urgent.

2. High level of ignorance.

To a large extent, many people including many of those expected to provide EH services have not fully appreciate the significance of the environmental dimensions of health and the correct issues involved. Specifically many people particularly mothers have not fully understood the link between personal/public hygiene, health and disease as well as the ways to break the link. In addition to these, many policy makers and professionals still hold on to the restrictive bio-medical approach to health and disease.

Where knowledge is low, incomplete or incorrect, there is the tendency that people’s ability to make informed decision about their health would be limited and their exposure to risks aggravated.

3. Poor political will and commitment.

In many places, there is poor political will and commitment. This lack of will also include the lack of will to make realistic plans and the poor will to implement plans. EH services required commitment on the part of all stakeholders towards the realization of program goals. It must be appreciated that mobilization in favor of improved ER has been poor, non-specific and sometimes misdirected. There is need to increase the commitment of all. This is particularly required at the LGA level.

4. Poor funding of EH Services.

Funding for ER services have been poor over the years compared with other sub-sector. Though it is difficult to obtain how much had been spent by each tier of government on ER , it is generally believed that the sector had not been favoured in the allocation of needed resources. In many states of the federation, many LGAs are without a functional refuse van while other implements required are either insufficient or non available. The success of most EH programme is directly dependent on the amount of resource inputs and this has to be appreciated. In addition to this, lack of resourcefulness is another factor that has bedevilled the sector. In most cases, the little resources allocated are really not available to prosecute ER services due to undue corruption. In many places, EH services are seen as one of the main conduit pipes through which funds are siphoned. The need to be more resourceful is considered very important.

5. Training and Human resources Development.

By an large the training of most ER personnel takes place at the state government-owned Schools of Health Technology/Hygiene which are expected to be of the status of a Monotechnic . There are about 35 of such schools in Nigeria. The standard of many of these schools leaves much to be desired. Coupled with this is the fact that the country used to be the pioneer of a University-based ER training programme in Africa. The then UNIFE (Now Obafemi Awolowo University, Ile-Ife) B.Sc EH programme was famous during its years of existence as the only one in Africa. Today the story is different as the programme was rationalized under questionable circumstances around 1990. Training and human resources development must be seen as an important aspect of evidence- based ER service delivery. The Council’s effort in this direction is welcomed and its expected to be complemented by training institutions so that more competent professional could be trained.

The way forward

Moving ER service forward in Nigeria requires a radical approach towards the provision of improved services. The services are expected to be universally accessible to people irrespective of where they live. It should also be culturally, economically and socially adapted to each local setting and directed towards addressing specific health and development problems.

To make environmental health a really potent force in the 21st century, important changes are needed. To some extent, these changes are a problem of money and resources and pose a political question: what priority should be given to environmental health within the full array of social needs and wants? But they also raise problems in communication, in education and in technology development itself

Reflecting WHO’s corporate strategy, EH activities should focus on six strategic areas of work which are:

• Ethical and evidence-based policy.

• Stimulating research and development, testing new technologies and comparing performance.

• Technical and policy support for sustainable capacity building.

• Setting. validating, monitoring and guiding the implementation of norms and standards.

• Assessing status and trends.

• Developing tools and guidelines for disease control and risk reduction.

Revitalization of environmental public health services in the country is important for four reasons:

1. Many environmentally related conditions affect the health and lives of millions of citizens at significant cost,
2. Many emerging and re-emerging public health problems require innovative enviromnental public health services interventions,
3. Environmental public health is an important part of the public health response to terrorism and other emergencies, and
4. Environmental public health services issues are becoming more complex.

Specifically, the following has to be addressed as a way forward for effective ER in

Nigeria:

1. EH policy and Regulation.

There is need for Government at all levels to ensure that policies are directed towards addressing environmental health problems. Policies must clearly indicate what is to be done, by who and also include system for monitoring and evaluation of activities. In addition to this, there is need for appropriate legislations to address specific issues. The obsolete Public Health Laws (1958/59) as applicable in different parts of the country must be reviewed. EHOAN/EHORECON’s initiative to get a suitable legislation should be supported by all. If there are grey areas that need to be addressed, this should be sorted out.

2. Advocacy.

In a system where both government and individual priorities are misplaced in disfavour of ER, the need for a planned advocacy strategy becomes very needful to sensitize all stakeholders towards improved services. There is need for both policy advocacy as well as personal advocacy in favour of ER. To ensure service sustainability requires indigenous advocacy. In this wise everyone must be involved. Everyone who cares can be an effective policy advocates. The media has a unique role in this strategy particularly in providing correct information to members of the public, in letting the government know what they should be doing, and in advocating for good practices.

3. Intensifying Hygiene Education

ER professionals must take leading responsibility in modifying their approach to providing ER services. It must be clear to all that most traditional approaches towards service delivery are no longer fashionable. Efforts must be geared towards achieving positive behavioral changes in matters relating to El-I. This might require a review of the present curriculum of instruction in the training schools as well as a re-orientation of all stakeholders.

4. Inspiring a Shared vision.

Application of the concept of shared vision is important for improved EH services. Efforts directed at improvement as well as the strategies to be adopted must be shared among all stakeholders. Shared vision demands partnership and collaboration which is expected to have multiplier effects towards realization of targets. Coupled with this is the need for team work among all stakeholders. Levels of government must see the joint responsibility in ensuring a safe environment for health.

5. Fostering Leadership

This is important so as to ensure that the goal of ER services is enhanced by environmental public health services and also develop strong working relationships among the stakeholders in EH services and to assist state, tribal, territorial, and local health entities and other stakeholders to improve the practice of EH This goal requires development of a National programme to create a cadre of well-trained specialists who will become leaders at all levels of ER service delivery. The professional association in collaboration with the Council would be expected to champion this course.

6. Communication and Social Marketing

The intent of this goal is to improve communication and information sharing among EH professionals and other public health agencies, communities, policy makers, and others and enhance the significance and understanding of environmental public health. Achieving the goal also will define the structure of an effective system for sharing EH information. This goal will be accomplished by promoting and disseminating strategies. Education approaches, and models of best practices to engage communities and policy makers in discussions about EH issues.

7. Developing the Workforce

This strategy is expected to promote the development of a competent and effective EH workforce to deliver contemporary services and address emerging needs. Implementation of this approach includes defining the scope of work as well as the size, composition, performance standards, and competencies of the ER workforce and its current leadership. Accomplishing this goal will include activities that outline ways to develop an EH workforce training stem. Development of the National Environmental Health Service Corps or a fellowship program is also a critical component. In addition, these activities will support programs to increase the number and elevate the status of ER practitioners who engage in competency-driven continuing education and training.

Conclusion

In today’s world, efforts to ensue or maintain high levels of EH status in addition to traditional concerns need to take account of the broad development agenda as well as a number of often complex processes or phenomenal. In doing this, it is time governments at all levels stop paying lip service to ER matters. It must be appreciated by all that no nation can ache desirable level of development without proper EH delivery Government the people, the professionals and all other stakeholders must champion a course in ensuring a healthy environment in Nigeria and for Nigerians.

References

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