When in 1854, Florence Nightingale (1820-1910), a well-educated English lady from an aristocratic family, who is still fondly remembered as The Lady with the Lamp, volunteered, along with 37 others, to tend to wounded soldiers during the Crimean war (1853-1856), she found the soldiers in a deplorable condition. Their wounds were dirty and suppurating. They were housed in filthy, overcrowded, poorly lit and feebly aerated rooms shared with rodents. No attention was paid to hygiene and sanitation where they were kept. Understandably, they were dying in large numbers from various afflictions including cholera, typhoid and dysentery.
She set to work by giving them good food and cleaning their wounds. She provided warm, quiet and less crowded accommodation with better aeration and sunlight in the belief that manipulating the client’s (patient’s) environment, facilitates the body’s reparative process. With time, the soldiers became of better cheer; their wounds healed faster and fewer numbers of them died as a result of the war injuries as well as the insanitary conditions in which they were kept. That principle of the body’s reparative powers, and by extension, health, being affected by the environment – physical, psychological, social and others, either negatively or positively, is regarded as the first of the over twenty Theories of Nursing that currently exist. It is known as the Environmental Theory and it is ascribed to Florence Nightingale1.Consequently, the environment is now recognised as an important determinant of health for individuals and communities.
The environment in this respect is regarded as the complete surroundings in which humans live and interact, including the land, sea, and atmosphere, along with all their contents, such as forests and vegetation, water and faunas as well as air and microorganisms. In their pristine forms, these elements exist in a balance that sustains the natural environment. However, human activities arising from acts of daily living such as construction of houses and roads resulting in a built environment, extraction and exploitation of the earth’s resources, destruction of forests, and the disposal of waste materials, change the environment and alter its equilibrium, sometimes, with disastrous consequences for health as well as other factors. Concern for the short, medium and long term consequences of these deleterious effects that are brought about by stresses on the environment on mankind’s well being and continued existence on earth, has been continually expressed by world leaders.2,3 and 4
Environmental Health, on which today’s lecture is largely hinged, takes its bearing from the Environmental Theory. It is the branch of Public Health that seeks to promote health for all through the fostering and encouragement of healthy environment as it is known that the environment directly affects health status and plays a key role in the quality of life and years of life lived in good health. It is for these reasons that the Millennium Development Goal 7 advocates sustaining the environment as a significant way of improving quality of life. Therefore, as we now know, there exist several environmental factors that affect health.
In today’s lecture, I will very briefly discuss some of these factors that are of global concern. Next, I will address a few of them that are more relevant locally, in our country, Nigeria, in some details. Dealing with the issue of environmental factors that affect health at these two levels, will naturally lead to a discussion on the concept of Environmental Sustainability and the related subject of Sustainable Development – two issues that are at the core of Environmental Health. I will conclude by elaborating on how General and Private Medical Practitioners can help to sustain the environment, not least, for the sake of the health of their patients. But before I do so, I will draw attention to the nexus that exists between Environmental Health and General Medical Practice. In the presentation, emphasis will, at all times, be placed on promoting good health and preventing ill health through a positive engineering of the environment.
GLOBAL ENVIRONMENTAL HEALTH ISSUES
So many and diverse are the issues that are currently of global concern with respect to the environment, that an attempt to discuss all of them in a lecture such as this will not be feasible. So, from the wide range of issues such as climate change, pollution, waste generation and management, including medical waste, deforestation, land degradation, and many more, I will only touch on two, and even at that, only briefly – climate change and pollution. Climate change currently constitutes one of the greatest challenges of modern times because of the protean nature of its effect. Similarly, pollution of land, sea and air from man’s activities is progressively rendering some environment unsuitable for human habitation.
Climate change denotes a remarkable change in temperature of the earth which is felt globally. The phenomenon is caused mainly by human activities especially those involving the burning of fossil fuels and coal for the purposes of obtaining energy – an action which results in the production of carbon dioxide.
Normally, much of the atmospheric carbon dioxide is usually mopped up by plants for food production during the process of photosynthesis at which time, oxygen is also released. However, increased production of carbon dioxide with the concomitant reduction of plants through massive felling of trees, results in an accumulation of the gas which gets trapped in the atmosphere leading to the anthropogenic or increased natural greenhouse effect, trapping of solar heat and global warming. Furthermore, other gases such as methane and nitrous oxide, which also enhance global warming and deplete the protective ozone layer in the stratosphere are also produced by human actions, including mining, live stock farming, use of commercial fertilizers as well as the use of chlorofluorocarbons in manufacturing processes.
Global warming on its part, leads to significant climate and weather changes which result in raised sea levels with associated coastal flooding and decreased snow cover at the earth’s poles with a myriad of problems, some of which will be touched upon later.
Pollution is the introduction of contaminants which are in gaseous, solid or liquid forms into the environment that cause harm or discomfort to humans or that damage the environment. Pollutants are produced mainly through human activities and they commonly affect the air, land and water. Common pollutants include particulate matters, sulfur dioxide, carbon monoxide and nitrous oxide. These elements are released from burning fuels, industrial activities, cigarette smoking and some chemicals.
LOCAL ENVIRONMENTAL HEALTH ISSUES
Plurality of issues of serious environmental concern also exist at the national level as they do at the global. For instance, not unlike the hurricanes that now characterise weather patterns in North America, Nigeria noticed heavy floods between July and October, 2012, which affected 32 out of its 36 States. More than 7 million people were displaced of whom over 300 died. Additionally, 600,000 houses were either damaged or completely destroyed.
However, for the same reasons as were given earlier, I shall discuss only two of the many environmental concerns – desert encroachment on the one hand and the devastation caused by oil exploration and exploitation activities on the other. In effect, both have to do with land degradation – by the desert in the north and by oil prospecting activities in the south.
Drought and the advancement of the desert in Nigeria have become so grave that they were included in the short address of President Goodluck Jonathan to World Leaders at the Rio+20 World Congress on Sustainable Development in Brazil, in June, 2012. As for the negative outcomes of the oil explorative activities in the country – especially those on the environment – so serious are they, that they have attracted severe local and international condemnations.
President Goodluck Jonathan, while speaking at the United Nations Conference on Sustainable Development (UNCSD), also tagged Rio + 20, which took place in Rio de Janeiro in June 2012, warned that Lake Chad might disappear completely in 20 years. To prove his point, he cited the fact that the lake shrank from about 25, 000 sq kms in 1964 to less than 2,000 sq kms as at the time of his address.
The shrinkage of Lake Chad and desert encroachment are all arising as part of the phenomenon of increased aridity that has become a feature of the climatic condition in Nigeria, especially in its northern parts.
Desertification, by which fertile land turns into barren land or desert as a result of drought, over exploitation of grass and vegetation, is affecting several parts of Nigeria, notably, Sokoto, Kebbi, Zamfara, Jigawa, Katsina. Available data indicate that the desert is encroaching southwards at the rate of about 15 km annually in contrast to the situation that existed four years back when estimates were far less. Consequently, the country is losing about 350,000 hectares of land every year to desert encroachment. Thus, land for human habitation, agricultural and pastoral activities is lost, leading to serious demographic, social and economic consequences that affect health and well-being.
DEGRADATION FROM CRUDE OIL EXPLORATION
Crude oil (petroleum) was found in Nigeria in commercial quantities in 1956 by Shell `D Arcy. Two years later, in 1958, the first barrel was shipped out for sale in the international market. From this small beginning, the industry has burgeoned to include deep water and off shore drilling and has now become the nation’s major commercial business, eclipsing all others, including agriculture, which until then, was the major source of employment and revenue for the country. With proven oil reserves of over 36 billion barrels and average production of over 2 million barrels per day(Mbopd), exploration activities are intense in parts of southern Nigeria, where almost all the reserves are concentrated but especially so in Rivers, Bayelsa, Akwa Ibom and Delta States.
Proceeds from the sale of crude oil so obtained have been immense; Dr. Obi Ezekwesili, Nigeria’s former Minister of Education in her recent address to the congress of the All Progressive Peoples Party (APC) on 6th. March, 2014, reckoned that Nigeria had so far earned 600 billion US dollars from the sale of crude oil!. Despite the profligacy and corruption that have allegedly attended the utilization of this massive inflow, the huge capital has enabled the country to build infrastructure, create new cities, advance its social services especially in the health and educational sectors and much more. But all this has been at a heavy prize of severe dislocation in the social fabric of the people and massive degradation of the environment in which they live and work. Violence, armed conflict, kidnapping for ransom, vandalism, sabotage, oil theft and bunkering for perceived injustice and criminality, are all prevalent in the littoral states that are oil bearing. As for the environment, no part of it has been spared the harmful effects of crude oil exploitation and exploration. Drilling for the so called black gold takes place on land (on shore) and at sea (off shore); transportation of the crude, does as well. Often, the crude spills, of which there have been over 4,000 instances, destroying marine life, annihilating farms and arable land and polluting drinking water in streams and wells. Bunkering and illegal refining of crude, devoid of regulations and accepted safety precautions, pose severe danger as they pollute the air, inflict injuries on humans and leave the land desolate – neither fit for habitation nor agriculture. Additionally, there is the issue of flaring of the associated gas that comes up during exploration into the atmosphere. Sadly, this has been in Nigeria for the past 50 years even though serious efforts are currently being made to harness some of the gas, especially with the establishment of the Nigerian Liquefied Natural Gas Company. The noise, huge flames, perpetual light, heat and emission of poisonous gases that are associated with gas flaring are all injurious to health in many ways. It is to some of these ill effects that the recent United Nations Environmental Programme (UNEP) Report on environmental degradation in Ogoni land drew attention5.
One of the most visible consequences of the numerous oil spills in the country, has been the loss of mangrove trees which serve as a source of energy from the burning of its wood by the indigenous people of the Niger Delta. The mangrove forest also constitute a vital part of the area’s marine ecosystem Thus, their progressive loss has led to a depletion of the marine life in the area. Additionally, the oil spills have adverse effects on marine life, which become contaminated, with negative consequences for human health from the consumption of contaminated seafoods6.
As for gas flaring, even when it ends, air pollution is likely to remain a problem in the country, as other sources, especially the many diesel-operated electricity generating plants which are popular on account of the well-known poor and erratic electricity supply from the national grid. Gas flares cause atmospheric pollution by releasing particulate carbon and hydrocarbons into the air, which the inhabitants inhale, causing cough, dyspnoea and watery eyes. Additionally, disturbed sleep rhythm occurs in some persons because of the bright light and heat from the flares6. Finally, available information suggests that some blood disorders, leukaemia, some cancers and congenital malformations, occur in association with oil exploration activities.
ENVIRONMENTAL SUSTAINABILITY AND SUSTAINABLE DEVELOPMENT
The point was made earlier that through various acts of daily living, mankind brings changes to bear on the environment. Such changes lead to resource depletion, as occurs in extractive industries and deforestation, pollution as in water contamination by chemicals, carbon dioxide accumulation as in fossil fuel consumption, toxic fumes as in waste increases and much more. The net effect of these pressures is that the environment becomes poorer and is less able to respond to mankind’s welfare and other needs. Thus, Environmental Sustainability consists of preventive and remedial actions that seek to maintain the capability and quality of the environment – its atmosphere as well as its renewable and non-renewable resources – in an indefinite manner or for a long time.
Paradoxically, the acts of daily living to which reference is being made, are in themselves, mostly geared towards development and improvement in mankind’s quality of life. Clearing of forests is often undertaken to build roads, houses and cities; industries are established to manufacture much-needed goods and also provide employment; vehicles are driven for mobility and access; fishing is embarked upon to provide food and leisure. Taken together, these actions and many more, result in atmospheric carbon dioxide increase, especially from fossil fuel combustion, which then accumulates, as a result of its accelerated production and longevity as well as concomitant tropical forest depletion for a variety of purposes, giving rise to an enhanced natural greenhouse effect and global warming with all its attendant consequences on the environment. Furthermore, these activities lead to a diminution of the earth’s resources (minerals, marine life, forest resources), pollution of water as well as air (surface water contamination from factory chemicals, air pollution from toxic industrial fumes) degrade the land (oil spillage from exploration activities) and accumulate waste – human, industrial, household and others, including radioactive and medical waste materials. It is this contradiction that exists between the concept of sustainability on the one hand and the demands of development on the other, that makes some scientists consider the two as oxymoron. So, for environmental sustainability to succeed, development process must be sustainable.
Faced with this dilemma, policy makers and executors as well as programme implementers in public and private establishments globally, have embraced the concept of Sustainable Development as a collective responsibility of mankind to save the earth (environment) for present and future generations. The idea is for the present generation to meet its developmental needs without endangering the developmental needs of future generations. To achieve this desire, there are plethora of conventions, resolutions, treaties, accords, policies and agreements to preserve the earth and its natural resources and to support, promote and enhance sustainable development. They cover topics in the areas of the atmosphere, water resources, marine environment, hazardous substances, air quality, drainage, energy, waste, nature conservation, terrestrial living resources, noise pollution, nuclear safety and much more. The Kyoto Protocol on greenhouse gas emission reduction of 1997 is one of such treaties.
Although compliance has not been perfect due to a variety of reasons, including differences in national interests, the conventions and treaties, among others, bind nations to subject their operations – policies, manufacture, purchases, constructions, institutions and others – to the concept of sustainability. Thus, they are to reduce their rate of consumption of the earth’s resources, decrease their waste production, recycle and reuse commodities as much as possible, and preserve the environment to the best of their ability in all their daily activities. Furthermore, they are enjoined to reduce carbon emission as well as other greenhouse gases like methane, and to exploit environmentally- friendly sources of renewable energy like solar and wind.
Preserved in this manner, the environment is better able to support and promote health. Sustainable Development thus becomes an important contributor to Environmental Health.
ENVIRONMENTAL HEALTH AND GENERAL MEDICAL PRACTICE
The International Conference on Primary Health Care (PHC) which was held in Alma Ata, USSR, 6-12 September 1978, aimed for the protection and promotion of health of all the people of the world. It regarded health as a fundamental human right and argued that the protection of the health of the people is essential to sustain economic and social development and to contribute to a better quality of life as well as to world peace. It went further to define 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 (where they live and work) through their full participation and at a cost that they can afford. It indeed saw PHC as a continuing health care process, that should extend from cradle to grave.
Primary Health Care is universal health cover and it is practised largely at the community; not in large General and Teaching Hospitals, where emphasis is usually on the management of ailment of individuals. Thus, its execution is essentially the responsibility of General Medical Practitioners and Family Physicians who work closest to the generality of the people. Furthermore, it is also at the community level that efforts to address the root causes of ill health through improved preventive health strategies can be most effective, as actions at that level address the concerns of members of the community as opposed to those of individuals. Safe drinking water is supplied for the community so that people do not have diaorrheal diseases. Blocked drainages are opened for the community so that mosquitoes do not thrive and enhance the chances of malarial infection . Refuse from the community is disposed of properly so that disease-carrying rodents do not flourish . Playgrounds are provided for children in the community so that some of them do not become obese from inactivity with resultant metabolic disorders, and others. I am of course referring to modifiable environmental factors such as preventing cholera infection in hundreds of people in a community by ensuring that the well from which they all drink, contains uncontaminated water. Such modifiable environmental factors have been shown to be responsible for one-quarter of global disease burden and more than one-third of the burden among children7. Not only does this finding establish a nexus between environmental sustenance (health) and General Medical Practice, it additionally places a heavy responsibly on those with the calling to be in the vanguard of all efforts aimed at preserving the earth and its environment for the sustenance of human welfare.
A good number of these environmentally-mediated diseases that can be prevented through a healthy environment need to be addressed through policy options by governments, business conglomerates and institutions. But there is also a long list of them about which General Medical Practitioners can do a lot. They include diaorrheal diseases – faeco-oral transmission through unclean hands and contaminated water, respiratory tract infections -poor indoor and outdoor air quality from tobacco smoke, fossil fuel use, malaria – stagnant or slow running water as in drainages that allow mosquitoes to thrive, intestinal helminthiasis -.soil contamination by excreta, tuberculosis – overcrowded living environments, cancers – exposure to pollutants, neuropsychiatric disorders – fragile and violence prone environments, and many others.
Let me elaborate a little further by quoting some excerpts from the findings and conclusions of a study that was commissioned by the WHO7.
- Environmental factors contribute to 23% of all deaths worldwide and 36% of all deaths among children 0-14 years.
- An estimated 24% of all deaths in children under 15 are due to environmentally- related diaorrhoea, malaria and respiratory infections; these same three killers also represent the largest share of the childhood environmental disease burden.
- An estimated 42% of the global malarial burden, or half a million deaths annually, could be prevented by environmental management. Globally, about 1.5 million deaths per year from diaorrhoeal diseases are attributable to environmental factors, essentially water, sanitation and hygiene.
- Smoking is the largest risk factor for lung cancer, but environmental factors also account for an estimated 31% of lung cancer burden.
- Globally more than 1.5 million deaths annually from respiratory infections are attributable to the environment, including at least 42% of lower respiratory infections and 24% of upper respiratory infections in developing countries.
- Crowding and certain home or workplace exposure to air pollutants are environmental factors that increase the burden of disease from tuberculosis.
- Infants of mothers exposed to air pollution, environmental tobacco smoke and other chemicals have higher rates of low birth weight.
- More than half of the global population gets insufficient physical activity to protect them from a range of non-communicable diseases, heart disease, cancer of the breast, colon and rectum as well as diabetes mellitus.
- Developing regions carry a disproportionately heavy share of environmental disease burden.
As can be seen therefore, environmental factors play an important role in global disease burden. Ensuring that the environment of his patient is healthy, thus becomes an important preoccupation of the General Medical Practitioner and Family Health Physician.
Let me commence my concluding remarks by expressing my sincere gratitude to the officials and members of the Association of General and Private Medical Practitioners of Nigeria (AGPMPN) for inviting me to deliver today’s Dr. Samuel Etim Ande-Ewa’s Memorial Lecture, the 24th in the series. In your letter of invitation, you reminded me that this is the second instance your great Association is extending to me, the honour of delivering a guest lecture at its conferences, the first being in 2002 – the only other previous occasion at which this city of Port Harcourt has had the privilege of hosting your conferences. The unusual concession of a second appearance at this forum deepens the burden of my indebtedness to you – Long May Your Association Live.
In the past couple of minutes, I have spoken on Environmental Health Issues and how they impact on the professional practice of General Medical Practitioners. I have argued that on account of this relationship, Environmental Health has become an important component of the brief of every general medical practitioner. The issues I discussed, in a way, were derived from the theme of this year’s conference: Environmental Protection and Health in a Developing Economy which I consider timely, judging from the severe stress the earth and environment are currently going through. Internecine struggles in Syria, Egypt, Iraq, and Libya where Arab springs appear to have gone awry, and of course, not forgetting the unfortunate and endless killings in parts of our own country. Ukraine is simmering. Massive global youth unemployment forcing some to a recourse in violence – terrorism, aggressive confrontation with constituted authorities, lands denuded of life giving trees, hurricanes, floods, population explosion, food insecurity – the list just goes on- are all current stark realities. Globalization with its associated unprecedented movements has made the world a global village. In the midst of all these shearing forces which tend to break the earth as it were, there is a need to pause and to reflect on protecting the environment, not least, for the sake of future generations. Here let me say that it would be foolhardy for anyone to suggest that this should be left to the environmentalists alone since they are the experts. My position is that protecting the environment should be everybody’s business. And for us, more so, as a protected environment is a more beneficial one which in turn better supports and promotes the health of the community where our patients live and work. A protected environment is a better platform for health from which everyone benefits.
It is this search for a platform for the greater good to the larger population that fired the minds of the likes of Dr. Samuel Etim Andem-Ewa to look away from the big General and Teaching Hospitals and to establish private practices through which the community could be better accessed. Elected in 1976 as the pioneer President of the Association of General Medical Practitioners of Nigeria – an association of like-minded persons that shared a common vision – he served in that capacity meritoriously for a decade during which time, the association laid the foundation for an academic faculty at the National Postgraduate Medical College of Nigeria. In other words, he recognised that human capital is the most sustainable human resource. I therefore commend the Association for holding these annual lectures in honour of such a visionary man and true proponent of Public Health.
So, with respect to environmental issues and environmental health, what is the way forward? Broadly, we have to fall back on the principles of sustainability or long term availability. We should curtail our demand and reduce our usage of the earth’s resources, especially where these resources are non-renewable – and this with particular reference to the extractive industry. An important step in this regard, to my mind, is to reduce the number of people making such demands on the resources of the earth – the global population issue to which all countries of the world contribute. Here, available information is that Nigeria is not doing well. Despite free contraceptive services, our fertility rate of 6 births per woman as estimated in 1990 has only declined to 5.5 in 2013 according to the 2013 Nigeria Demographic and Health Survey, published by the Nigerian Population Commission. Members of this great association should take up the population issue and convey to their patients the advantages of slimmer families.
Still on the extractive industries, the point has to be made that standards better than what currently obtains in Nigeria have to be instituted. Frequent oil spills on land and sea, gas flaring and poor management have all combined to make activities in this sector, one of Nigeria’s most environmentally unfriendly. Evidence exists to show that Nigerians living in oil producing areas are more prone to a number of disease conditions. This has to be reversed.
As for PHC and its role in addressing environmentally-related issues at the community, a number of positive things have happened in recent times which the Association should take advantage of. One is the passage of the National Health Bill by the Senate on February 19, 2014 and the other, the launching of the Universal Health Coverage by Mr. President at the Summit on Monday, March 10, 2014. Whereas the former seeks to properly streamline the health care delivery system in the country, the latter drums up strong support for PHC, especially its financing, committing the nation to a 30% health insurance cover for Nigerians by the end of this year. The Association should see its hands strengthened by these two events to enable it tackle the health related environmental issues. Furthermore, the World Economic Forum recently announced that its next regional forum for Africa, will hold in Nigeria for the first time, in May, 2014. As the largest private sector participators in Nigeria’s health industry, I urge your members to take full advantage of this forthcoming forum where policy makers, and chief executives will meet to map out the future direction of economic growth in Africa.
Finally Mr. Chairman, I notice that Easter is round the corner – a period set aside in the Christian faith to commemorate rebirth, rejuvenation, reawakening and indeed, hope. These are the very essence of sustainability – the underpinning element of Environmental Protection – the theme of the conference and Environmental Health – the title of my address. So, as I wish the blessings of Easter on us all, I commend us to one another and implore that we be not consumed by intense anger, or utter resentment or for that matter, helpless resignation over our current challenges as a people. But that we brace up our selves and put aside those actions that have set us back over the years as they are wasteful and non-sustainable. Dr. Samuel Etim Andem-Ewa and his fellow compatriots would urge us on in that direction were they alive today. I thank you all for your attention.
1. Nursing Theory and Conceptual Framework, Fundamentals of Nursing: Human Health and Function, Ruth F. Craven and Constance J. Hirnle, 2003, pp.56
2 . United Nations Conference on Sustainable Development, held in Rio de Janeiro, Brazil, on June 20-22, 2012.
3.The 20th. Ordinary Session of the African Union, Addis Ababa, 26th. May, 2013.
4.World Economic Forum, Davos, Switzerland, 22-25 January, 2014
5. United Nations Environmental Programme. Environmental Assessment of Ogoniland 2011.
6.Oruamabo, RS, (2005), The Effects of Environmental Assaults on Human Physiology. Guest lecture delivered at the 25th Annual Scientific Conference and Silver Jubilee Celebrations of the Physiological Society of Nigeria.
7. Pruss-Ustun, A, and Corvalan, C. Preventing Diseases through Healthy Environments. World Health Organization.
ENVIRONMENTAL HEALTH: A PILLAR OF GENERAL MEDICAL PRACTICE, 24th. SAMUEL ETIM ANDEM-EWA MEMORIAL LECTURE. Association of General and Private Medical Practitioners of Nigeria(AGPMPN) on April 3, 2014 by NIMI BRIGGS, University of Port Harcourt.