THE CHALLENGES OF ENVIRONMENTAL HEALTH OFFICERS IN PRIMARY HEALTH CARE IMPLEMENTATION

By S.A. Ojewale, being an invited paper presented at the 39th National conference/scientific workshop of the Environmental Health Officers Association of Nigeria [EHOAN], at the Banquet Hall, Lagos Airport Hotel, October, 2003


Abstract
Since 1977, when the World Health Assembling endorsed Primary Health Care [PHC] as the new model for building health systems, progress in establishing accessible, affordable and appropriate health care has been painfully slow.
Following this, in May 1978, an international conference was headed by WHO member states in a town in former USSR called Alma-Ata where 134 nations including Nigeria declared that PHC is the key to attaining ‘health for all in the year 2000’.
Many health professionals were involved in the policy formulation, planning & implementation of PHC in Nigeria; one of such health cadres is Environmental Health Officer [EHO]. Environmental Health Officers are always in the fore-front since the inception of PHC in Nigeria, diagnosing, sieving & coping with the challenges arising from the implementations of PHC. This paper therefore, discusses where and what these challenges are and how EHOs are coping with the challenges now and in the future.




Introduction
Primary Health Care is posing a lot of challenges to Environmental Health Officers, the challenges, which are implicit or embedded in the definition, concepts, and also in the components of PHC, are so overwhelming and inundating that it is only those Environmental Health Officers that are articulate, well abreast, scientific with adequate native intelligence that could meet and tackle the challenges, many of which have reached crisis or danger point, after all when things [challenges] are going tough only the tough can get going.

Definition of PHC
I would have preferred to define PHC as people oriented service built on the axiom of health of the people, by the people, and for the people [Bamigboye 2001] and not perceived as the exclusive prerogative of health professions as observed by Lambo [1995], but the challenges will not be so glaring as I would want them. Even then, Environmental Health Tutors Officers should have it at the back of their minds that PHC requires concerted efforts and there should not be any role or professional conflicts or wrangling among all the stakeholders.

More importantly, PHC as defined by Alma-Ata in 1978 is essential health care, based on practical, scientifically sound & socially acceptable methods and technology, made universally accessible to individuals and families in the community and country can afford to maintain at every stage of their development in the spirit of self-relevance and self-determination.

Any discerning listener will quickly realize that there is more to the issue of interpreting correctly the definition and concept of PHC than its implementation. There are underlying disagreements over how PHC problems are defined, their degree of seriousness, who is responsible for solving them, and how amenable they are to solution. These disagreements run deep, they are based on different professional training, moral principle, different values and different assumptions.
In Nigeria, every health worker including EHO talks about Primary Health Care (PHC) but if you ask them to define or explain the term, they often offer funny explanations. This shows that as important as the program,, is, it is still not well understood even by those who are expected to plain and implement the programme. We must assist each other in the process of interpretation by identifying the appropriate context, that is which the actions concerned make the most sense.

CONCEPTS OF PHC
The concepts of PHC are equally important in its implementation just as its definition is, of course, the concepts are entrenched in the definition because, it must be socially acceptable to the people, scientifically simple and at a minimal affordable cost.
One may be tempted to gloss over the issue of affordability but it is a serious and indicting challenge. For instance, since 1977, when the World Health Assembly endorsed Primary Health Care (PHC) as the new model for building health systems, progress in establishing accessible, affordable and appropriate health care has been painfully slow. While expanded coverage of preventive and curative services has saved millions of lives, many of these gains have proven to be short lived. In many cases, the benefits of investments continue for only as long as funding lasts. In the poorest countries, Nigeria inclusive, dependency on external support is increasing especially for PHC services. Thus, despite considerable efforts and enthusiasm for PHC, neither governments nor donors have been successful in fostering lasting change in local capacity to deal with health problems in the developing countries. At Local, State and Federal Government levels we have Environmental Health Officers as PHC coordinators, Expanded Programme on Immunization (EPI) or measurement and Evaluation Managers. The big question is how sustainable are these programmes are at local, state and federal levels?

It is reported that the Primary Health Care (PHC) agenda rested on two hidden assumptions. One was the expectation that the world economy would continue to grow as it had throughout the 1960s and 1970s. The Second presumed that the volume of external support for PHC would increase to enable the transitions of PHC in developing countries. Neither of these assumptions was ever realized because of recession and debt, the oil crisis and declining terms of trade began to cripple the economies of many countries, it has not improved to date. What is more challenging than this?

COMPONENTS OF PRIMARY HEALTH CARE (PHC)
I want to further illustrate the challenges of Environmental Health Officers in Primary Health Care (PHC) implementation by making reference to ten components of PHC. In this regard, I am completely ignoring the artificial but lose boundaries created between the components earmarking them for specific health cares. The obvious reason is that the Environment i.e. the sum total of the conditions within which organisms live directly or by implication embraces all the PHC components. It is therefore logical to assert that all the ten PHC components discussed here are sources of challenges to Environmental Health Officers.

MATERNAL AND CHILD HEALTH (MCH)
Maternal and Child Health (MCH) aims at promoting the health of mothers of child being age and their children, so that children have the opportunity for normal growth and development and so that the reproductive life of women does not constitute too much risk to their health and well-being. The situation of MCH is Nigeria today is not encouraging, Nigerian is one of the countries where maternal and infant mortality rates are very high, the condition become exaggerated and exacerbated by poor economic conditions and non-challant attitudes of males to reproductive health.
As long as MCH remains the exclusive reserve of Nurses and Midwives, many husbands and fathers of which Environmental Health Officers are, may not see the need to encourage family planning and exclusive breast feeding (Baby Friendly Initiative). Men should co-operate with women in reproductive health.
Early marriage leading t teenage pregnancy with a; its numerous complications and pregnancy in quick successions are inimical to the health of mothers. Environmental Health Officers should see and accept this as a challenge. They should not be alienated in what MCH or reproductive health is all about. Maternal and child health syllabus could be incorporated into the West African Health Examination Board (WAHEB) Curriculum.

PROVISION OF ESSENTIAL DRUGS AND APPROPRIATE TREATMENT OF COMMON DISEASES
Here Environmental Health Officers (EHOS) are rising up to met the challenges in the areas of Onchocerciasis, Guinea-worm, Tuberculosis and Leprosy (TBL) eradication control programmes. I am aware that many EHOS are TBL managers having undergone an intensive training in Kaduna. But for the Carter Foundation, Nigerians would have known that Dracontiasis is prevalent in our midst. The versatility of EHO training and the resilience of an average EHO are the hall mark which made it possible for the cadre to be actively involved in guinea-worm, Onchocerciasis (River blindness), tuberculosis and leprosy control and eradication programmes. The challenge to wipe out these diseases is not beyond human achievement. Environmental Health Officers (EHOS) played noble and major roles in the total eradication of smallpox in the early 70s.

PREVENTION AND CONTROL OF LOCALLY ENDEMIC DISEASES
In Nigeria, malaria fever, Schistosomiasis, meningitis etc. constitutes endemic diseases which contribute greatly to both morbidity and mortality of children and adults. All these diseases are preventable and can be controlled.
One of the prominent challenges of EHOS is PHC implementations is the problem of malaria fever. The scourge has been with us since and in the South West Region of Nigeria, it was comment in those days to see sanitary inspectors as they were called then holding a big ladle to sample stored water for mosquito larvae and pupae. Culprits were prosecuted and penalized. But this had gone with our colonial masters.
Malaria is a global crisis, which as a household world in the sub region is taken for granted. A Roll Back Malaria (RBM) survey shows that 1/5 of the world’s population is at risk of malaria. This proportion increases yearly as a result of climate change environmental degradation, breakdown in Health care and wars.
This survey also reveals that there are 400 million cases of malaria illness each and at least one million people die annually. Most of these deaths occur in African children and he number is growing. Malaria often in combination with other diseases kills a child every 30 second. The survey further states that among pregnant women malaria is wide spread causing low weight babies and stillbirths. Nearly 60% of miscarriages are due to malaria. It is a major killer of refugees in Africa. This background is necessary as stimulant so that we will know what we are facing.
Roll Back Malaria (RBM) founded by the government of malaria affected countries, WHO, UNDP, UNICEF and the World Bank met in Nigerians in year 2000 to see how they can half the burden of malaria for the world’s people by the year 2010.
Current WHO initiatives in malaria control such as Roll Back Malaria (RBM) emphasize the use of insecticide-treated nets (ITNS) as one of the key strategies for malaria prevention and control in sub-Saharan Africa. UNICEF and WHO have set the goal of providing 32 million nets and 320 million net treatment a year for the next decade to protect 80% of African households from malaria (West African Journal of Nursing Vol. II No. 2, November, 2002).
To start with, the sudden and astronomical rise in cases of malaria is a tacit indictment on our professional competency. We need to brace up and join the other stake holders, we cannot afford to be complacent and rely on past glory old fame, it is a matter of how do we stand now, not how we stood then small pox was eradicated.
It is clear from the information provided in many health education campaigns in sub-Sahara Africa that there is still confusion surrounding effective methods of individual and community malaria control. For instance, in many areas, it is suggested that people and communities should cut the grass and bushes in their premises as means of preventing malaria. However, it has been shown that this does not reduce the incidence of Anopheles (the genus of mosquito that transmits malaria). In sub-Sahara Africa female Anopheles mosquitoes predominantly feed late at night when most people are in bed, most frequently biting between 10:00 pm ad 4.00 am. Day-feeding culex mosquitoes do not carry the malaria parasites and therefore cannot transmit the disease. As of now insecticide treated nets (ITNs) is yielding positive result if field reports are anything to go by. Right now, the net has no contraindication but there are human barriers to the use of this net. This is an aspect of the work of EHOS, to create awareness of the safety and effectiveness of ITNs.
However, ITNs should be seen as a panacea or a fool proof approach to malaria control. Environmental, physical, biological and chemical control should be intensified more than ever before. Premium should be on Environmental, physical and biological control using community based and integrated approach.



FOOD AND NUTRITION AND DENTAL HEALTH
A hungry dog is an angry dog so says a proverb: This is true because except there is abundance supply of food items and at affordable means, the gospel of Primary Health Care will be falling on deaf ears. Environmental Health Officers are not agricultural officers but they can evolve an intersectoral collaboration to ensure food surplus. However, food adulteration, contamination due to poor handling or from dirty premises is quite challenging and common. We should closely work with National Agency for Food and Drug Administration (NAFDAC) in eradicating the use of poisonous chemicals as food additives, flavours enhancers and preservatives. Environmental Health Officers (EHOs) have been too silent and complacent on the war against the use of potassium bromated commonly used by bakers. Reports indicated that potassium bromated is carcinogenic.
Since the supported taking over of anti-mortem inspection of animals by the veterinarians, EHOs are not forthcoming in inspecting meat and meat products when such are display in markets. It is common nowadays to find uninspected meat and meat products being displayed for sale in markets. The gullible and innocent members of the public are paying dearly for this because many must have been infected with one food borne disease or the other especially bovine tuberculosis.
Wholesome food cannot come out from dirty surroundings. Many food preparing and eating premises are so filthy that they server as regular sources of food contamination. Many consumers could have picked such ailments like typhoid fever, dysenteries, gastroenteritis, cholera and other bowel diseases from food serving as vehicles of infection. This is a challenge that must be faced squarely.

ENVIRONMENTAL HEALTH
Environmental Health is an integral part of PHC but it is an extensive field. It includes water and basic sanitation, housing, food and nutrition, vector control, control of communicable diseases, disinfection and disinfestations, and control of pollution. Some of these components have been highlighted in this paper but I will like to emphasize water and basic sanitation, because these are areas posing challenges to EHOs in the implementation of PHC.

WATER SANITATION
To say water is everywhere and that it is abundant for use is a tantalizing statement, quite misleading and erroneous. Water is a renewable resource and some 70% of the earth's surface is water but 97% of that is ocean. By volume, only 3% of all water on earth is fresh water and most of this is largely unavailable. About three-quarters of the fresh water is locked away in the form of Ice caps and glacier located in polar areas far removed from most human habitations only about 1% easily accessible as surface freshwater. This is primarily the water found in lakes, rivers, and the soil at underground levels shallow enough to be tapped at an affordable cost. Only this amount is regularly renewed by rain and snowfall in form of hydrological cycle.

THE COMING WATER CRISIS
Fresh water is emerging as one of the most critical natural resource issues facing humanity. World population is expanding rapidly. Yet there is no more fresh water on earth now than there was 2,000 years ago, when the population was less than 3% if its current size. Water is, literally the source of life on earth. The human body is 70% water. In growing number of places people are withdrawing water from rivers, lakes and underground serves faster than they can be recharged. Population growth alone will push an estimated 17 more countries with a projected population of 2.1 million into these water short categories within the next 25 years, already 31 countries mostly in Africa and the near East are facing water stress or water scarcity (Population Report Series M, Number 14)













Malin Falkenmanrk developed the concepts of water and water scarcity based on an index of per capita fresh water need. He estimated a minimum need of 100 litre per peron for household use and from 5-20 time a much for agricultural and industrial use.
Water dispute are now a major headache in our community. The available water sources are exposed to gross pollution from animal, domestic and industrial source. What can be more challenging to EHO this time around? The proliferation of packaged drinking water a.k.a. pure water is complicating the problem. Many of this packaged water are constant source of infection. We should create awareness that water is a precious natural resource that should be judiciously used & cared for to make it wholesome.
SANITATION
Sanitation of the environment forms a strong pillar of PHC. If there is 100% immunization cover age, and there is enough food and potable water, filthy or dirty environment will negate and render useless what could have been dividends. Hence, sanitation is basic and fundamental. Sanitation is a system made up of nature, society, process and device.






When discussing sanitation, and particularly in relation to the environment, we have to consider all these components. We cannot afford to neglect any one of them. Effective and efficient environmental sanitations alone is capable of achieving between 70-75% of a healthy population that the entire components of PHC could achieve. This is because many of the PHC problems are environmental based, but this could not be achieved on platter of gold it is an arduous and Herculean challenge to all Environmental Health Officers.
Nobody including layman is satisfied with the present arrangement of refuse disposal or is it disposal or dispersal of refuse? At best, it is refuse removal than refuse disposal.
Surely there is waste crisis, because the three basic principles of waste management are not being applied. For instance, there is the need to protect Health and Environment, minimize the Burden on future generations and conservation of non-removal resources. These three principles have been derived from the philosophy of sustainable development [fig 2].







Fig. 2: Sustainable Development and the Waste Management Principles


As long as these three basic principles are ignored in waste management, problems of wastes shall linger on and remain a stubborn challenge to Environmental Health Officers.
Presently, there is no clear cut policy on the method to be adopted in disposing refuse at local, state and federal government levels. In Oyo state for instance, what is being practiced now is nothing but sanitary landfill. The people in the local government where the municipal wastes are being tipped are experiencing all sorts of environmental hazards and risks. Their land and water are polluted and large quality of farm product destroyed by methane gas. No wonder, such things like ‘not in my backyard’, ‘NIMBY’, ‘not in my term of office’, ‘NIMTOO’, ‘locally unacceptable land use’, ‘lulu’, etc., are in vogue. It is a fact that land is no more available for waste disposal.

Wastes are very democratic-they are produced by each and every one of us, and so we should all contribute to the solution. Because of the populist nature of waste, its management is very much a social problem. It is not sufficient to understand the technical aspects, it is equally important to come grip with the social and political issues, and we must seek effective solution within practical cost limitations.
Environmental Health Officers are also facing the challenge of the nylon used to pack ‘pure water’. This nylon is a non-biodegradable substance and will not accept incineration either ,because it will emit poisonous gas-dioxins . the are other polymers and polyvinyl chloride[PVC]that will emit dioxins ad furan when they are incinerated .
The growth of advertising, along with electronic media, played an important role in evolution to society current level of over consumption. The end result was a dramatic increase in the amount of variety of consumer goods and hence, garbage to compound the problem, packing became dominant force in the way good were marketed ,distributed and sold. Today packaging represent more than one third of entire waste streams [Blumbers & Gottlieb, 1989).

The sustainable development concept is generally applied to the ‘front end’ of the industrial cycle the aim of ensuring that human can feed, clothe, house and entertain themselves. It is particularly relevant in preserving our diminishing resource but sustainable development must also be applied to the ‘back end’ of the consumer cycle, the management and disposal of waste. The situation as it is remains blinds pot.
It is apposite to mention that it will not be in the interest of a clean environment and the general masses to make EHOs subservient to another cadre, it is colloquial, and a manifestation of colonial vestige.
Primary Health Care recognizes professionalism, intesectoral collaboration and concerted approach inform of consortium. The present arrangement whereby in many Local Government Medical Doctors sit down in office to oversee waste management is an aberration and a waste of human resources. They are more needed in the clinics to improve the dwindling curative services. Environment Health Officers (EHOs) can work effectively and efficiently if they are allowed to do this in a conducive atmosphere.

HEALTH EDUCATION
Most of the challenges facing E.H.Os from the implementation of Primary Health Care can be overcome through Health Education approach but Health Education itself as a component of PHC remains a challenge to Environment Health Officers.
We have not tried enough to convince the masses that health is a valued asset that should be worked for, to attain. Our attitude to the masses is that of dealing with lay unintelligent people that should be planed for not planned with. Many of enabling factors in Health Education are violated with impunity resulting to mass failure of many of the policies, programmes and projects in P.H.C.
Communications skills are very important in Health Education and to be effective, health workers need to know the facts on how to prevent ill health and treat illness. This information must be communicated to the people to improve the health of their families.
Good communication is a two-way sharing of information. It involves finding out people’s view, listening carefully to what they say and understanding their situation i.e. includes being observant and appreciating the constraint people face.
Environmental Health Officers (EHOs) should be encouraged to develop behavioural technology adequate far the solution of environmental problems inherent in the implementation of PHC. The root of the word technology is a Greek term that means art, craft, or skill-in other words, knowing how to do something.
The term behavioural technology refers to the science, art, skill or craft of influencing socially important human behaviour. There is imbalance between physical and behaviour technology resulting in many health or environmental problems.
Most behaviour relevant to primary Health Care can be thought of interm of the three components of an operant paradigm described by B.F. Skinner (1953). This model is symbolized by the term SD-R-SR. In the model, a discriminative stimulus (SD) set the occasion for a response®. One could think of an SD as a signal that particular context. The response itself will act upon the environment that the world around us sometimes changes as a function of what we do. These changes are symbolized by SR which can be either positive or (SR+) or negative (SR).
The above analysis simply confirms what Health Education explains that “every behaviour is caused”. It is therefore imperative for EHOs to see laws as a last resort especially for stubborn and recalcitrant people.

Environmental Health Officers (EHOs) should intensify environmental education more than ever before to curb environmental degradation, destruction, distraction and disruption resulting in global warming, Ozone depletion, drought, desertification, the Greenhouse effect urban heat Island, EL-NINO-effects and other natural and anthropogenic hazards and risks. They are environmental challenges that have direct being with PHC. There is new and stronger evidence that most of the warming observed over the last 50 years is attributed to human activities observed the international panel on climate change (IPCC). The 2001 IPCC report says Global surface temperature have increased between 0.4 and 0.80C since the late 19th century. The pertinent question is Global warming armful to health? It is predicted that global warming will expand the incidence and distribution of any serious medical disorders. Mosquito-borne disorders are projected to become increasingly prevalent since mosquitoes proliferate faster and bite more as the air become warmer. As the whole areas heat up, then mosquitoes could expand into formerly forbidden territories bringing illness with them. There are also the effects of flood and drought both of which can result in polluted water supplies:
As I mentioned earlier, environmental degradation and destruction have direct effect on P.H.C planning and implementation. Environmental Health Officers have major role to play in the implementation of PHC, if the implementation is going to be successful.



SUMMARY
This paper has tried to explain in simple language what is Primary Health Care ( PHC), its concepts, and the components and how they are related to Environment Health Officers (EHOs). It was emphasized in the paper, that EHOs are faced with so many challenges in the implementation of PHC and that Environmental Health Officers have crucial role to play in the successful implementation of PHC.

RECOMMENDATION
In order to meet the challenges of PHC by Environmental Health Officers, I am recommending the following:
1. That Environment Health Officers should be well abreast of the PHC concept, aims and objectives and components
2. Environmental Health Officers should realize that PHC requires concerted efforts and that no professional group has the prerogative to dominate PHC
3. Role or professional conflicts should be avoided
4. The (EHOs) should pursue more academic activities than hither to.
5. Environmental Health Officers should know that they are stakeholders and partners in progress in PHC implementation
6. Environmental Health Officers should be more articulate in generating revenue either at Local, State or Federal Government Level.

CONCLUSION
Generally, the tempo of Primary Health Care (PHC) is going down and is no more gathering momentum. Health for all by the year 2000 has been elusive and remain a mirage. The vestige remains the expended programme on immunization (EPI) all other components are almost in moribund. If we cannot achieve health for all by year 2000. PHC should be rejuvenated, resuscitated and brought back to life. It will go long way to improve the health of the masses.










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