Sunday, October 28, 2012

Evolution of Environmental Health and Emerging Challenges: The Role of Practitioners

By Prof M.K.C. Sridhar
Evolution of environmental health is more than two hundred years old. Through the timeline, the earlier concerns on the communicable diseases due to polluted water and poor housing and sanitation have drifted to more complex chemical pollution, contamination of water and food, air pollution, and industrial disasters. Some of the newer challenges include hitherto unnoticed or less suspected bacteria, protozoa, HIV/AIDS, avian flu and their relation to poor hygiene and sanitation or inadequate waste management practices. Newer monitoring tools, technologies and procedures have become challenges for the environmental practitioners. Environmental Health Officers in particular have to be geared to meet such challenges and implement national edicts and guidelines in protecting the environment and safeguarding the health of the communities.
Key Words: environment, practitioner’s pathogens, pollution, communicable diseases Environment Health and Environmental Practitioners.
Environmental health is “the control of all those factors iii man s physical environmental, which exercise or may exercise deleterious effect on his physical, mental or social well being“. The scope of environmental health is broader as compared to sanitation in that it embraces a wide variety of components. In particular, as defined by WHO in 1 952, ii refers to the control of water supplies, to ensure that they are pure and wholesome, methods for the disposal of excreta, sewage and community wastes to ensure that they are adequate and safe, housing, to ensure that it is of a character likely to provide as few opportunities as possible for the direct transmission of disease (especially respiratory infections), and encourage healthful habits in (lie occupants, milk and other food supplies, to ensure that they are safe, personal and 1iuhlic habits of cleanliness, especially in relation to disease, arthropod, rodent, mollusk or other alternative hosts associated with human disease, and atmospheric conditions to ensure that the external atmosphere is free from deleterious elements and that the internal conditions of workshops, houses, etc. are suitable for the occupations undertaken in them”.
Environment belongs to every profession and every skill or expertise has a role to play. It cuts across all disciplines, walks of life and even international boundaries. Anybody with environmental concerns and skills t improve his immediate environment is a practitioner. While addressing the environmental matters one has to follow ecosystem approach so that a holistic approach is made in the control of man made mistakes. This paper addresses the challenges that pose to modern day Environmental Practitioners and in particular the Environmental health officers who have a major role to play at grass root level in implementing the national policies and guidelines.
Evolution of Environmental Health
Environmental health had its roots in castern religion, particularly Hindu Vedic scriptures. In the words of Rabindranath Tagore (Poet Nobel Laureate of India), the culture of the forest has fueled the culture of India”. Three to live thousand years ago, Taoism and Confucianism explained and helped people follow the patterns of nature. In the west, Egyptian, Sumarian, Babylonian and other civilizations have extensive and intricate links between nature and the divine. The revered prophets of Judaism, Buddhism, Christianity and Islam also renewed their link to the divine by retreating into nature. The earliest recorded mention of any form of health control is contained in the Bible when Moses led the children of Israel out of Egypt, the eating of the flesh of swine was forbidden because the animal was considered ‘unclean’.
The biggest advance in promoting health came with the Romans. They devised the first while carriage sewage disposal, hot and cold running water, central beating and regular bathing. Evidence of these advances arc found in the remains of Roman Settlements throughout Europe and the U.K. Archimedes of Eurcka frame, even made a contribution wit Ii the Archimedes Screw, a device used to raise water from a lower level e.g. a stream, to a higher level. All these benefits were lost or forgotten a for I lie departure of (ho Roma us, and Britain, together with the rest of’ the civilized world for several hundred years sank into an environmental limbo.
The industrial revolution of the [8th century while bringing material gains also brought new problems — slums, accumulation of refuse and human excreta, overcrowding and a variety of social problems. Frequent outbreaks of cholera added to the woes. Chadwick’s report (2) of 1842 on ‘The Sanitary Conditions of Labouring Population focused the attention of the people and Government on the urgent need to improve public health. Filth and garbage were recognized as man’s greatest enemies and it lead to great sanitary awakening bringing Public Health Act of 1848 in England, in acceptance of (lie principle that ‘(lie state is responsible for the health of the people’. The act was made more comprehensive when Public Health Act (I 875) was enacted. Environmental Health Officers (formerly Sanitary Inspectors amid Public Health Inspectors) have been looking after the public’s health since 1848. The work today reflects both (lie problems brought about by modern lifestyles, and some o (lie older problems which still face many members of the community.
The public health movement in USA followed closely the English pattern. The origin of the PHS in USA can be traced back to the Act for the Relief of Sick and Disabled Seamen that was signed by President John Adams on July 16, I 798. The organized professional body, American Public Health Association was formed in 1872.
In districts where no public health inspector is appointed, the chief constable of the district shall act as public health inspector, and all the duties and powers assigned to a sanitary inspector may be performed anti exercised by him, or by any constable designated by him for that purpose. The Chief of Police (Bridgewater Police Department, Nova Scotia, Canada) in 1899 also served as “Sanitary Inspector and Truant Officer”. Typical activities were hiring a horse and wagon to convey prisoners to the Lunenhurg jail, a prosecution for giving tobacco to a minor, enforcing Nova Scotia’s Temperature Act and enforcing quarantine for families and individuals stricken with Diphtheria, Scarlet Fever, Small Pox and the like. The first “lock up,” owned and shared with the Municipality (County), was said to be “not a fit place to put a man” arid “is very unsatisfactory as well as dangerous to prisoners and properly” - no heat ... and damp all the  time and no toilet. These conditions continued till 1918.
Sanitary reforms commenced in Lagos in 1877 with the appointment of the first Inspector of Nuisances. Subsequently by 1897 Lagos had both a Medical Department and Sanitary Department with Dr H. Strachan as Chief Medical Officer, W.M. Mackisen as Sanitary Engineer and W.F. Lumpkin as Inspector of Nuisances. Sir William MacGregor, the first Governor (1899) may be remembered for his contributions to environment as he was the “Golden Age” (Sridhar 1999). Environmental Martyr Ken Sarowiwa (Landow 2006) succinctly put the roles played by the Sanitaory Inspector, not leaving out the corrupt practices of yester years (Box 1)
Today’s public -health movement varies dramatically from the wave of activism in the nineteenth and early twentieth centuries. Then, the main emphasis was stopping ‘contagion’ by altering the conditions under which infectious disease spread. This is still a crucial issue in the South where the basic necessities of clean water and adequate food top the agenda. In the industrial world, however3 the main focus is dealing with chronic diseases (cancers heart ailments) and their causes. The modern ‘environmental movement, born in the crucible of I 960s discontent’, is an important factor in the field of public health
Roles and Responsibilities of EHO
The EHO ensures that the environmental health standards in a community are being developed and maintained at acceptable levels. This is done through health promotion and the identification, evaluation and control of those factors in the environment which could impact negatively on the health of individuals and communities. Local Governments, private companies and other organizations employ EHO, and wherever they work, they have a common goal - to protect the public from environmental health risks. To achieve this goal, EHOs are always ready to give advice to individuals, community groups, companies and committees. Health promotion and health education are used as vital tools to promote environmental health issues and bring about improvements. They can resort .to legal action only when education and persuasion fail.
Sir Benjamin Ward Richardson, president of the Liverpool’s Sanitary Inspectors Association, UK in the 1890s, described EHO as “....someone who would not be afraid to inspect any nuisance or other contagious disorders. It was necessary that he should be what was called a respectable man, and he has to be to some extent presentable in private houses. His duties were labourious, his salary contemptible. I designed him in his first days as the “Forlorn Hope of Sanitation” which may colleague, Edwin Chadwick, thought was a happy description”. The chartered institute of Environmental Health referred EHO as “Amicus Humoni Generis” or “Friend of the Human Race”. To find person and induce him to be responsible to get the job done, and this primarily a problem of policing. Enforcement called for an inspector of robust physique and  ........Character. The forming and humanitarian ideas of the period were accompanied by an often conflicting belief in laisse==faire, and the resistance of owners of unhealthy property was vigorous and unabashed.
There are about 3000 registered EHOs in Nigeria. The work of today’s EHOs is extremely varied. The majority of them is employed by local Government and State and has the task of protecting people living or working in their area. They work in either generalized or specialized department. Generalist EHOs are responsible for all aspects of environmental health in a particular part of the Local Government. For specialists work either singly or as part of a team is responsible for a particular aspect of environmental health, such as air pollution or food safety, throughout the areas.
EHOs also work for private industries, advising companies of their legal duties and helping them maintain good standards from within the organization. In industry abroad they are often referred to as Environmental Health Advisors or consultants. Other EHOs are employed by the Army, Navy and Air Force, Civil Service, Universities and Colleges. In recent years an increasing number have become self-employed, working as consultants for many clients, in both the public and private sector. There are challenges ahead. They have to wake up to the tasks and bring back the glory of what they were intended for in a society. There are many areas other than sanitation in which their services are required particularly during environmental disasters and after (Box 2).
The career of the EHO is a changing and challenging one. It is related to people, their environment, housing, their recreation, prevention of illness, remedying conditions which are a health risk, public guidance and far more. In short, it is the task of the EHO to protect the people of the community where he or she practices from any conditions which could be hazardous to their health.
Challenges of Today
  1. i.          Pollution Monitoring and Control
Pollution of air, water and soil is a growing concern. Newer technologies are adding up more difficultly degradable chemicals requiring innovative technologies to manage them. However, the good news is that of cleaner production technologies and phasing out of zone depleting substances from the industrial menu. National and International consciousness is rising. However, the local action is not matching with the world in general. Monitoring and controlling pollution levels and educating the public in protecting the environment is fundamental to the work of environmental practitioners. An increasingly important aspect is raising environmental awareness and conducting environmental “audits” in industry and communities. If pollution levels are too high and above the national permissible limits set by the Ministry of Environment, the health of both the public and the environment can be put at risk.
EHOs keep a close check on the levels of air, water and noise pollution in their designated areas, and communicate this information in a way that is meaningful to the public. Shortage coupled with poor distribution system has contributed to the increasing cases of water-borne diseases including typhoid, cholera, gastroenteritis, and more than 20 other infections in the country. Newer infections such as legionella (first reported in 1976), cryptosporidium (first case diagnosed in 1976), Helicobacter pylori (linked to gastric acidity 1982) and Campylobacter, E. coli 157:H7 (recognized as pathogen in 1982) and HIV/AIDS (antigens found in medical wastes in 1982 are emerging and challenging the public health practitioners. Disinfection resistance is also on the increase and the occurrence of opportunistic pathogens is on the increase. The monitoring of pollution is also changing from water borne pathogens of last century and persistent organic pollutants of modern day. Endocrine disruptors, PCBs, trihalomethanes and a host of very risky chemicals are entering the water distribution system and EHOs are to be prepared for recognizing their sources and prevent their entry into water and food chain. Hazard Analysis Critical Control Points (HACCP) as a tool which has been used in food premises is being extended to water quality and the environmental practitioners are to acquaint themselves of this latest tool.
EHOs are responsible for monitoring the levels of airborne emissions from small and medium sized industrial processes and can take action to cut the levels if necessary. Noise is also considered as a pollutant, from equipment, power generating sets, industrial boilers and compressors, fans to late music nights or burglar alarms and EHOs have to be impartial and find a dangerous waste is a potential danger to health. Recent incidents such as ‘Koko’ waste dump, and several oil spills in the Niger Delta State are eye openers. This area is an example of how EHOs work alongside other professionals, such as land developers, architects and engineers, to provide a multi-disciplinary approach to problems.
On the infrastructure scenario, there is a lot to be done in Nigeria. There are no laboratories which are well equipped (except a few private ones serving oil companied) which can cater to the needs of environmental monitoring. Many a time the results reported are questionable and do not tally with inter-laboratory quality control or quality assurance indices. It is high time that every state should have at least one well equipped laboratory manned by a qualified Scientist. These scientists are to be certified from time to time trained and retrained and QA and QC should be made mandatory at regular intervals. Even the equipments they use should be checked by qualified maintenance engineers and should be condemned if they do not meet the quality criteria.
  1. ii.           Food Sanitation and Hygiene Control
Ghana played a prominent role in the West African region in 19th century. Food and sanitary inspectors monitored markets and kept an eye on the conditions under which food was sold. An indoor market was a radical re-definition of the West African concept of the marketplace. In Ghana, fish sellers were strictly female, though men were the fishermen. As the fish was transferred from the canoes to the women (“fishwives”), it entered a distinctly feminine ..... market hygiene was valued.
................................ In Nigeria today are deplorable. Every year thousands of people suffer silently from food poisoning and food borne infections. Chemicals, heavy metals, parasites, fungi, viruses and bacteria can cause food borne illness. Bacteria related food poisoning is the most common, but fewer than 20 of the many thousands of different bacteria actually are responsible. More than 90 percent of the cases of food poisoning each year are caused by Staphylococcus aureus, Salmonella sp., Clostridium perfringens, campylobacter jejuni, Listeria monocytogenes, vibrio parahaemolyticus, Bacillus cereus, and Enteropathogenic Escherichia coli. These bacteria are commonly found on many raw foods. Salmonella is now considered as a dangerous organism, small in size and migrate from the egg shell into the yolk unnoticed. Inspection for food safety should focus on the processes that the foods undergo, with particular attention to possible sources of contamination to which foods are exposed; modes of contamination; effects of the process on the level of contamination; probability of microorganisms surviving processing and chances that bacteria or moulds will multiply during processing or storage. Food safety rests on controlling food operations from receipt of ingredients until the processed or prepared foods are distributed, sold or eaten. Surveillance should emphasize operations rather than physical ..........
Only now the Federal Ministry of Environmental is putting in place a Policy and Food Sanitation Officer or Environmental Health Officers are concerned with ensuring the safety of food, at all stages of production and distribution, until it reaches the consumer. EHOs inspect food premises and advise managers on hygiene and safety matters. If the conditions in premises are a risk to health, the EHO may take legal action by serving an improvement notice, or in very extreme cases, close the premises until the problems are put right. However, the vast majority of EHO work in this field is concerned with advising businesses on food law and regulations and helping them to safeguard their customers. EHOs may also run courses to educate food handlers and promote initiatives to raise the consumer awareness of how to prevent poisoning in the home.
  1. iii.        Housing
In the early 1840s, and perhaps ten percent lived in cellars in UK. The borough engineer (New Castle-Up-On Tyne painted a lurid picture of the conditions in the early 1860s, enplaning how courts had no through ventilation and normally contained ‘the privy or ash pit common to all the wretched dwellings, with its liquid filth oozing through their walls, and its pestiferous gases flowing into the windows’. Conditions within the houses were no better. Good housing comes high on most people’s list of priorities for a decent standard of living. Environmental Health Officers monitor housing standards and can ensure that repairs to properties are carried out in order to make a house suitable for habitation. In many cities and large towns, slums are growing unchecked. Pressure of populations and unmatching infrastructure have resulted in poor structures and degraded environmental sanitation. EHOs are responsible for ensuring that people living in these premises are protected from fire and hygiene hazards. With little space available around the residential houses, some of the earlier guidelines are to be changed and supplemented with improvements in building technologies. It is estimated that in 1997 there were still around 1.5 million unfit houses in England. Lagos has been classified as a megacity Abuja is growing out of control and soon competing with Lagos. There are still lots of work to be done in the area of urban housing by the EHOs in association with town planners and other professionals. Provision of parks is to act as ‘lung’ for the cities, and this is neglected by most of the modern day administrators.
  1. iv.        Waste Management
Urban development unless properly planned is closely associated with unsanitary conditions and accumulation of filth and garbage. Technology is contributing to the changing composition of the waste. The older concept of target collection bins is being replaced by JRs (......... Recycle). More and more developed countries are advocating zero discharge to dump sites. Waste to energy concepts is replacing the traditional landfills and pyrolysis. Hazardous wastes, medical and infectious wastes from healthcare facilities, emergency wastes arising from such epidemics are avain flue are challenges and there is a need for emergency preparedness in handling,     transportation and disposal. Incineration and sanitary landfill are well known options, for Nigeria, recycling of non-biodegradable waste and concerting organic waste into compositing are the best environmentally friendly approaches. Biogas production is another viable option for organic waste management. This technology, once promoted will catch up as energy demand keeps on increasing with the developmental activities. In Nigeria there is no sewage system in any city (inclusive of Abuja). Open drains and septic tank system are the order of the day. In the long run centralized sewage system is more economical and efficient in managing waste waters from mega cities.
  1. v.           Health and Safety at Work
The industrial Revolution brought with it the many advantages of mass production, efficiency and quality, but also produced, in some circumstances, horrific working conditions. Over the past 150 years in United Kingdom various legal measures have resulted in continually improving safety standards. EHOs are responsible for enforcing the Health and Safety at Work (etc) Act 1974 in more than one million commercial and recreational premises employing some 9 million people. EHOs inspect premises and offer advice on how to protect employees and members of the public using the premises. They may also be called to investigate an accident and may prosecute if the firm is negligent. The main concern of the EHO is that conditions at work or in leisure facilities should not be detrimental to health. In the increasingly information-intensive environment of tomorrow’s health and safety, the role of Geographic Information System (GIS) will have greater importance due to its abilities to integrate a wide range of data sources, from legacy systems to image data, and to make complex data more quickly and easily understood. Unknowingly in the earlier years (1855) John Snow established the relation between broad street water source and the cholera outbreak in London. Snow took days to calculate his polygon around the Broad Street pump, something the GIS program does in seconds. Secondly, it provides an array of potent techniques-like nearest neighbor analysis and the spatial (or weighed mean) unavailable to snow and his contemporaries. Third, the ability of the GIS database to summarize and analyze data at a range of scales-local, regional, national and international-is an enormous boon. The breakdown of Health and safety inspection in a GIS perspectives is just one aspect of Environmental Protection and Health and Safety.
  1. vi.        Other Emerging Roles
Sustainable development is a catchy word since Rio conference. All the developmental activities before embarking are tied to environmental sustainability. Thus every country embraced the Environmental Impact Assessment, Environmental Audit and Health impact Assessment as part of their responsibilities. Every industry is mandated to develop environmental policies and environmental management plan. While technologically advanced countries adopted these almost immediately in their planning, the developing countries including Nigeria has started implementing very seriously. However, there are some basic problems affecting the quality of such studies and implementing the mitigation measures particularly in Nigeria. Pseudo environmental practitioners, say contractors get the jobs which are supposed to be technical in nature and hire unqualified environmental specialists to carry out the data collection. Here again, EHOs play very prominent roles at various stages.

Environmental practitioners of today have evolved over the centuries. Sanitary reform, especially developed by the Public Health Acts (187.., 1875) needed a well trained body of sanitary inspectors. The sanitary institute and other professional organizations set about improving the qualifications and standing of the people who were charged with creating a healthier urban environment on a day-to-day basis. The structures created at that time have changed much, but the posts, the professional associations and the journals that were created in late Victorian times are still valid today. There is no gain saying that we adhere to the older ways only. There is need to review the changing times and assign newer responsibilities and train them to fully equip themselves with the fast growing knowledge and technologic and procedures. The EHO is an environmental practitioner, a professional, a counselor, and a friend in deed to the communities at the grass roots.
  • Environment is dynamic and changes occur at short notice. Constant surveillance and action are necessary in remediating any irreparable damages.
  • In dealing with the environment, multidisciplinary nature of the management techniques should be realized and appropriately qualified or skilled personnel should be put in place with no bias or prejudice; Environmental practitioners should practice a multi-disciplinary approach by increasing diversification and breadth, rather than specialization and expertise.
  • One must recognize that traditional health promotion and education activities have often focused on messages to the individual regarding lifestyle choices to understand what is bad and what is good for them which has a minor impact on public health. This must expand to include broader communities and institutions
  • Any new approach must recognize that environment has a direct impact on health-through pollutants in the air, water and food-but also that environment affects the lifestyle, travel, food security, access to education, culture, green surroundings and social interactions
  • Unhealthy environment begets unhealthy lifestyles which in turn beget unhealthy environments. This can lead to a depressing spiral of decline. Environmental change can be achieve only through billions of individual lifestyle decisions.
  • At national level, the policy and guidelines should be backed up by unscrupulous implementation through the services of EHOs at various tiers; they should be strengthened with modern tools and training and retraining programmes.
  • There is need for well equipped laboratories at state or regional level to effectively monitor environment and they should be manned by qualified personnel
  • There is need for a deeper understanding of the factors that are detrimental to environment and health and the forces that encourage unhealthy lifestyles
  • R&D in industry and institutions is vital for coping with the challenges. This should be encouraged and the information obtained should be stored in database and disseminated through media.
  1. Sridhar, M.K.C and Oloruntoba Elizabeth. Environment and the Emerging Health Risks, Dokita, Journal of Medical Students of University College Hospital, Ibadan, (2005),30 NO. 1:10-23.
  2. MacArthur lan. Fresh in our minds, The 4th Thomas Fresh lecture, delivered to the Duncan Society in Liverpool, UK Public Health Association. 16  October, 2002. Originally published in Healthmatters, (2002), Issue 50, Winter pages 3..
  3. Sridhar, M.K.C. You, Your Health and the Environment, A Chapter in Nigeria’s Endangered Environment: Agenda for a Millenium, Edited by J.O. Abiodun, M.A. Foundation, Lagos, African Press Limited, (1999), pp. 185-203.
  4. Landow, G.P. Dukana Fetes the Sanitary Inspector, African Postcolonial Literature in English, Postcolonial Web by George P. Landow, Professor of English and Art History, Brown University, website, (2006) web page.
  5. Environmental Timeline, Webpage, 2006
  6. Thakur, H.P, Pandit D.D. and Subramanian, P. History of preventive and social medicine in India. J Postgrad Med (serial online) 2001 [cited 2006 Apr 10] 47:283-5. ISSN 0022-3859; 2001, 47; No. 4, 283-285.
  7. The Chartered Institute of Environmental Health (1997), Environmental Health-The Challenge, World Wide Web, 29 January 1997.
  8. Moses, A.. Nigeria: 70% Health Problem is Environment Related Council, This Day (Lagos), March 11, 2006, Posted to the web March 13, 2006.
  9. Bammeke, A.O. and Sridhar, M.K.C. Problems of fast indigenization on the quality of foods and beverages in Nigeria in Chemistry of Foods and Beverages: Recent Developments, Edited by Geoge Charalambous and George Inglett, Academic Press, Inc., New York (1982), pp. 171-179.
  10. Sridhar, M.K.C and Adeoye, G.O., Organo-mineral fertilizers from urban Wastes: Developments in Nigeria, The Nigerian Field, (2003), 68:91-111.
  11. Adedipe, N.A., Sridhar, M.K.C., Joe Baker, Krogmann, Uta, Verma Madhu, Nader Faruqui, Angela Wagener. Waste Management, Processing and Detoxification, Responses  Assessment, Chapter 10, (2005), Volume 3, pp. 1-61
  12. Sridhar, M.K.C., Coker, A.O., Aikhomu, S.I., Ifedayo, A.O. and Itodo, I.P. Biogas Production from Organic Wastes: Nigerian efforts, The Nigerian Field, (2003), 68: 112-124.
  13. Sridhar, M.K.C. Sullage/Water in Nigeria: Problems and Scope for Utilization for Gardening, A Monograph published by UNICEF, Lagos, Nigeria, (1995), pp. 1-63
  14. Brody, H.M.R. Rip, P. Vinten-Johansen, et al. Map-making and myth-making in Broad Street: The London cholera epidemic, 1854, The Lancet, (2000), 356, 64-68. (2001) Geographies of Health, Oxford: Blackwells. (Chapter 9)
  15. Brimblecombe, P., Historical perspectives on health, The emergence of the Sanitary Inspector in Victorian Britain The Journal of the Royal Society for the Promotion of Health, (2003), vol. 123, No. 2, 124-131.


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