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
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