Friday, January 25, 2013

ENVIRONMENTAL HEALTH: THE KEY TO SUCCESSFUL PRIMARY HEALTH CARE SERVICES DELIVERY


BY: DR. NURUDEEN SOBOWALE OLANIRAN,
Ag. Head, Department of Public Health,
College of Medical Sciences,
University of Calabar,
Calabar.
 November 20, 2012


 Your Excellency, Ogbeni Rauf Adesoji Aregbesola, the Governor of the State of Osun; The Honorable Minister of Health; The Honorable Minister of Environment, Housing and Urban Development; The Honorable Commissioner of Health, State of Osun; The Honorable Commissioner of Environment, State of Osun; Special Advisers, Permanent Secretaries here present; Directors in the MDAs here present; The National President, Environmental Health Officers Association of Nigeria; The Secretary/Registrar, West African Health Examination Board; The Registrar, Environmental Health Officers Registration Council of Nigeria-EHORECON, Our Royal Fathers;  Gentlemen of the Press ladies and Gentlemen.
1.    INTRODUCTION
The environment is so critical to the survival or death of man so much so that any human society that ignores this scientific fact does so at its own peril. All advanced nations of the world continually pay attention to the potential impact (positive or negative) of the environment on the citizens’ health and socioeconomic wellbeing. The relationship between environment and health has been discussed in detail elsewhere (Olaniran et al., 1995). In Nigeria, there is an urgent need for conscientizing the political class, policy makers, programme managers, and the entire citizenry on the critical issue of Environment and Health, and its role in Primary Health Care (PHC). The paper will present this topical issue by going from the general to the particular. Brief overview of Health, Public Health, Environmental Health and PHC; Challenges and Opportunities will be discussed.



2.    HEALTH
A popular dictum says ‘Health is Wealth”. However, in contemporary Nigerian society, it is self-evident that money, especially primitive accumulation of material wealth, is wealth. This misconception is primarily responsible for the nonchalant attitude of most Nigerians to preventive health care. Yet, it is generally accepted that “Prevention is Better than Cure.”
The World Health Organization (WHO, 1940), in the Preamble to the Constitution, defined Health as” a state of complete physical mental and social well-being and not merely the absence of disease or infirmity”. This WHO definition is utopian and unattainable by any person. Health of a person is so fluid and ever-changing. It largely depends on several environmental factors outside the control of a person, as well as complex personal genetic traits, socio-cultural attributes and negative behaviours. From the Environmental Health perspective, health is defined as a state of equilibrium between man and numerous, complex, physical, chemical, biological, psycho-social//socio-cultural factors in his environment. A state of disequilibrium (imbalance) results in disease or illness. This definition is less utopian and forms the basis of the epidemiological triad-Agent, Host and Environment. The Health profession comprises Public Health, Medicine, Pharmacy, Medical Laboratory Sciences, Nursing Sciences, Pharmacology, Radiography, Medical Statistics, etc. and their subspecialties/subfields.


2.1.                     POPULATION AND HEALTH ESTIMATES
Table 1 Population and Health Estimates for Selected Countries in West Africa.
S/N
Country
Population Health Estimates


Population (Mid 2012) x106
Births per 1000 popln.
Deaths per 1000 popln.
Infant Mortality Rate
% Popln Ages
Life Expectancy at Birth
Percent popln Urban
<15
65+
Male
Female
1.
Benin
9.4
40
12
81
44
3
52
56
44
2.
Cote d’Ivoire
20.6
35
12
73
41
4
54
56
50
3.
Ghana
25.5
32
8
47
39
4
63
65
44
4.
Liberia
4.2
40
11
83
43
3
55
57
47
5.
Nigeria
170.1
40
14
77
44
3
48
54
51
6.
Sierra Leone
6.1
39
16
109
43
2
47
48
40
Source: Population Reference Bureau (PRB), (2012)


Table 1 shows population and health estimates for six countries in West Africa. Benin, Liberia and Nigeria have estimated 40 births per 1000 population; Ghana has lowest number of deaths per 1000 population (i.e. 8) while Sierra Leone has the highest Infant Mortality Rate per 1000 live births (i.e. 109). The population in the six countries comprises mainly youths (39-44%) while only 2-3% are in the 65+ years age group. Females have higher life expectancy (i.e., live longer) than males in all the six countries. Nigeria has the highest percent of population in urban area (i.e. 51%). Nigeria Demographic and Health Survey –NDHS (2008) reported that 71.5 % and 45.3% of households used improved source of drinking water (potable water) in urban and rural areas, respectively. In the same survey, the proportions of household using improved sanitation facilities that were not shared were 31.4% in urban areas and 24.6% in rural areas. The NDHS findings are consistent with data from other studies indicating higher water supply and sanitation facilities coverage in urban than rural areas in Nigeria.

3.     PUBLIC HEALTH
Public Health is “the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals (Winslow, 1920). This classic definition of public health is all-encompassing and still subsists. Public health is multidisciplinary and multi sectoral as shown in subfields/subspecialties which include Environmental Health, Epidemiology, Biostatistics, Public Health Sociology, Health Education and Promotion, Occupational Health and Safety, Sanitary Engineering, Public Health Administration, Public Health Nutrition, Public Health Nursing, Family and Reproductive Health (Maternal and Child Health), Veterinary Public Health, School Health, Care of the Aged and Physically Challenged, International Health, History of Public Health and Public Health Law. Public Health comprises many professionals with varied but related complementary educational, technical and professional trainings. Public Health is therefore the umbrella profession for the 17 distinct subfields.
Public Health is as old as human history. From the beginnings of human civilization, it was recognized that polluted water and lack of proper waste disposal spread communicable diseases. Early religions attempted to regulate human behavior that specifically related to health, from types of food eaten to, regulating certain indulgent behaviours such as drinking of alcohol, or sexual relations. The establishment of governments placed responsibility on political leaders to develop public health policies and programmes to prevent disease as much as possible to ensure social stability and economic prosperity. The World Health Organization (WHO) is the international agency that coordinates and acts on global public health issues. In the United States of America, the front-line of public health initiatives are state and county (local) departments. The United States Public Health Service (PHS) coordinates most of its intervention activities through the Centers for Disease Control and Prevention (CDC) headquartered in Atlanta, Georgia.

In Canada, the Public Health Agency of Canada is responsible for public health, emergency preparedness and response, and infectious and chronic disease control and prevention. The Public Health system in Nigeria is subsumed under the Federal Ministry of Health whose major focus is curative health care instead of preventive health care. It is high time the Federal Government of Nigeria established a Public Health Agency to provide sharper focus and better funding for public health programmes to reduce the unacceptably high number of preventable deaths in the country.

4.     ENVIRONMENTAL HEALTH
Environmental health is the science and art of preventing, controlling and abating physical, chemical, biological, psychosocial//socio-cultural hazards in the environment that may adversely affect public health and the environment. A hazard is any substance, condition or factor that has the potential for adversely affecting public health and the environment. A hazard may be physical, chemical, biological socio-cultural or psycho-social.
Public health is endangered whenever hazards get to man through environmental pathways such as the air we breathe, the water we drink, the food we eat, the house we live in, the soil used for planting, and fomites, contaminated inanimate objects (e.g. disposable gloves and overalls of medical doctors and nurses).
The National Environmental Sanitation Policy (Federal Ministry of Environment-FMENV., 2005) defines Environmental Sanitation, a major component of Environmental Health, as “the principles and practice of effecting healthful and hygienic conditions in the environment to promote public health and welfare, improve quality of life, reduce poverty and ensure a sustainable environment”.
The Policy lists fourteen essential components of Environmental Sanitation as follows:
i.                   Solid Waste Management;
ii.                 Medical Waste Management;
iii.              Excreta and Sewage Management;
iv.              Food Sanitation;
v.                 Sanitary Inspection of Premises;
vi.              Market and Abattoir Sanitation;
vii Adequate Potable Water Supply;
viii. School Sanitation;
ix) Pest and Vector Control;
x)                  Management of Urban Drainages;
xi)              Control of Reared and Stray Animals;
xii)           Disposal of the Dead (man and Animals);
xiii)         Weed and Vegetation Control; and
xiv)         Hygiene Education and Promotion.
The components listed above are all essentially, subspecialty areas of Environmental Health. An experienced, well trained Environmental Health Officer (EHO) is expected to have acquired relevant knowledge, skills and technical know-how to initiate, execute and supervise Environmental Health programmes, activities and interventions in any of the fourteen components of the Policy. It is noteworthy that the Federal Ministry of Environment has also developed Policy Guidelines on Sanitary Inspection of Premises, Excreta and Sewage Management, Market and Abattoir Sanitation, Pest and Vector Control and Solid Waste Management.

5.     PRIMARY HEALTH CARE (PHC)
At an International Conference held at Alma Ata, WHO/UNICEF (1978) defined PHC as “… essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in a spirit of self-determination; it forms an integral part of both the country’s health system of which it is the central function and main focus of the overall social and economic development of the community; it is the first level of contact of the individuals, the family and the community with the national health system, bringing health care as close as possible to where people live and work and constitutes the first element of continuing health care process.’
This comprehensive definition is quite explicit; however, Egwu (2006) has provided other dimensions of PHC in Nigeria. Arising from this definition of PHC are some fundamental principles (National Open University of Nigeria – NOUN, 2008). The principles are:
i.                   Absolute responsibility of the government for the health of the people.
ii.                 The right and duty of people (individual and collectively) to participate in their own health activities.
iii.              Emphasis on preventive measures.
iv.              Equitable distribution and accessibility of health services
v.                 Application of appropriate technology through well-defined health programmes integrated into the national health system.
vi.              The social orientation of health workers of all cadres to serve the people.
vii.            A multi sectoral, multidisciplinary approach.
Under the dynamic leadership of the late Minister of Health, Professor Olikoye Ransome-Kuti, PHC as a strategy of Health for All by the year 2000 reached its zenith with adequate funding and high immunization coverage for the six childhood killer diseases. Nigeria also produced its first National Health Policy (FMOH, 1988). PHC service coverage, accessibility, etc have since nose-dived in many rural communities. Adeyemo (2005) has identified problem areas in PHC implementation in Ife-East Local Government Area, State of Osun.
Primary Health Centres are the last (lowest) level of health care in the Nigerian Health Care System. The next higher level is the Secondary Health Care (General Hospitals) while the apex level is Tertiary Care (Teaching Hospitals, Specialist Hospitals, etc). The National Primary Health Care Development Agency (NPHCDA) set up in 1992 is the apex body for coordinating PHC services in Nigeria. It has six zonal offices and operates in all the 36 states and 774 local governments – in theory. In practice, most rural dwellers do not have access to PHC services and many have no choice but to consult quacks or traditional healers for their urgent health needs (Bakare, 2012).
Components of PHC are:
i.                   Education concerning prevailing health problems and the methods of preventing and controlling them;
ii.                 Promotion of food supply and proper nutrition;
iii.              Adequate supply of safe (potable) water and basic sanitation;
iv.              Maternal and child care including family planning;
v.                 Immunization against the major infectious diseases;
vi.              Prevention and control of locally endemic and epidemic diseases;
vii.            Appropriate treatment of common diseases and injuries;
viii.         Provision of essential drug;
ix.              Community mental health care; and
x.                 Dental (oral) health.

6.     NEXUS OF PRIMARY HEALTH CARE (PHC) AND ENVIRONMENTAL HEALTH (EH).
The rationale for the link between PHC and EH is the fundamental principle and philosophy guiding the training of an Environmental Health Officer: Prevention and Control through Hygienic Practices and application of the Principles of Sanitation.  Hygiene, the science of Health and its maintenance, comprises a system of principles for the preservation of health and the prevention of disease. In practical terms, it comprises personal (individual) and community actions taken to preserve heath and prevent disease. An example is simple hand washing with water and soap after using the toilet. By contrast, Sanitation is the effecting of healthful and hygienic conditions in the environment by using measures such as drainage, ventilation, potable water supply, sewage treatment, medical waste management, air pollution control, etc.
Environmental Health Officers Registration Council of Nigeria – EHORECON (2007) has adopted WHO’s identified functions of Environmental Health Officers. The listed functions are:
i.                   Waste management;
ii.                 Food hygiene and control;
iii.              Pest and vector control;
iv.              Environmental health control of housing and sanitation
v.                 Epidemiological investigation and control;
vi.              Air quality management;
vii.            Occupational health and safety;
viii.         Water resources management and sanitation;
ix.              Noise control;
x.                 Protection of recreational environment;
xi.              Radiation control and health;
xii.            Control of frontiers, air and sea ports and border crossing;
xiii.         Pollution control and abatement;
xiv.         Educational facilities (health promotion and education);
xv.            Promotion and enforcement of environmental health quality and standard ;
xvi.         Collaborative efforts to study the effects of environmental hazards (research);
xvii.       Environmental health impact assessment (EHIA).
This elaborate list of EHO’s functions is quite ambitious and presumes that the current quality of training of EHOs in Nigeria with respect to scientific, technical and professional content, can meet the current complex challenges of Public Health in Nigeria. However, the identified functions above are controvertible evidence that Environmental Health is key to successful PHC services delivery in Nigeria. Furthermore, an EHO’s training stands him/her in good stead to implement health programmes and activities related to components i, ii, iii, v, vi, and x (over 50%) of the PHC components. Indeed, an EHO is a multivalent professional.
7.     CHALLENGES
The Environmental Health profession in Nigeria currently faces some challenges, like many other professions all over the world. Some of the challenges are:
i.                   The profession MUST put its house in order because a house divided against itself cannot stand. Struggle for supremacy must be jettisoned for the profession to grow and earn the respect of other health professions.
ii.                 Efforts should be made to train and retrain EHOs to enhance their skills and promote professional growth in line with global best practices.
iii.              Employment of more qualified EHOs at the Federal, State and Local Government and the private sector should be vigorously pursued by EHORECON.
iv.              A hungry officer is an angry officer. EHORECON should put political pressure on States and Local Governments that fail to pay salaries of EHOs as at when due.
v.                 Local Government authorities should always provide a stand-by waste evacuation vehicle so that solid waste accumulated on Environmental Sanitation days will not be washed back into the drainage system.
vi.              Climate change: Flooding and its serious public health challenges such as cholera, typhoid and other disease epidemics; pneumonia, venomous snake bites, general poor sanitation conditions,  lack of potable water supply, etc cannot be ignored. Environmental Health Officers must liaise with National Emergency Management Agency (NEMA) and relevant State Emergency Management Agency (SEMA) to manage public health emergencies arising from flooding and other natural or man-made disasters.
8.       OPPORTUNITIES
1. About eight Nigerian Universities now offer Public Health/Environmental Health courses at the Bachelor’s degree level. A few others offer Masters while one offers training up to PhD level. EHOs should seize this opportunity to strengthen and enhance their carrier.
2. The National Association should seek linkages with Pan American Health Association, American Public Health Association, Environmental Health Associations in the U.S and elsewhere. Canadian Public Health Association and others for sponsorship of many of your activities including short post graduate courses.
3. Contributions to the new Occupational Health Bill currently being debated in the National Assembly.
9.     CONCLUSION
Environmental Health is a crucial component of Public Health. Functions of an experienced Environmental Health Officer are quite extensive so much so that his role in PHC services is indisputable and indispensible. Environmental Health is indeed the key to effective PHC services delivery.
I thank you for your attention.

REFERENCES
Adeyemo, O.O. (2005). Local Government and Health Care Delivery in Nigeria: A case study”. J. Hum. Ecol., 18(2): 149-160.
Bakare, B. (2012). Improving Primary Health Care. Sunday Punch, Nov. 11, 2012. P 13.
Egwu, I. N. (2006). Primary Health Care System in Nigeria-Theory, Practice and Perspectives. Lagos: Elmore Publishers.
Environmental Health Officers Registration Council of Nigeria-EHORCON (2007). National Guidelines on Environmental Health Practice in Nigeria. FMENV, Abuja. Pp 4-5.
Federal Ministry of Environment-FMENV (2005). National Environmental Sanitation Policy. FMENV., Abuja.
FMENV. (2005). Policy Guidelines on Excreta and Sewage Management. FMENV., Abuja.
FMENV. (2005). Policy Guidelines on Market and Abattoir Sanitation. FMENV., Abuja.
FMENV. (2005). Policy Guidelines on Pest and Vector Control. FMENV., Abuja.
FMENV. (2005). Policy Guidelines on Sanitary Inspection of nPremises. FMENV., Abuja.
FMENV. (2005). Policy Guidelines on Solid Waste Management. FMENV., Abuja.
National Open University of Nigeria-NOUN (2008). Primary Health Care and HIV/AIDS. Pp 1-123.
National Population Commission (NPC) (Nigeria) and ICF Macro (2009). Nigeria demographic and Health Survey, 2008, Abuja, Nigeria. Pp. 21-22.
Olaniran, N.S., Akpan, E.A.; Ikpeme, E.E. and Udofia, G.A. (1995). Environment and Health-Module Eleven. Nigerian Conservation Foundation-NCF. Lagos: Macmillan Nigeria Publishers Limited.
Population Reference Bureau-PRB (2012). 2012 World Population Data Sheet, WashingtonD.C. USA.
Winslow, C.E.A. (1920). The Untitled Fields of Public Health: Science, 51 (1306): 23-33.
World Health Organization (1946). “Preamble to the Constituition of the World Health Organization”.