EHJ April 2004, pages 116-118
London EHO Bill Page recently visited Tanzania, looking at public health initiatives in Dar es Salaam's settlements. EHJ reports on his findings, comparing conditions with 19th century London

If Edwin Chadwick were to miraculously materialise in present day Dar es Salaam, the Victorian philanthropist would be astonished to find that people are still dying today because basic public health lessons, learnt over a century ago, are being ignored.

In the early 19th century, London's population reached a million. Drinking water was pumped from wells next to cesspits and water was being piped from rivers polluted with heavy sewage. Drainage was nonexistent, infant mortality stood at 30 per cent of live births, and communicable disease was rampant.

These are the conditions that prompted Chadwick to publish his seminal work, Report on the sanitary condition of the labouring population of Great Britain, which led to the birth of the environmental health profession. They are also the conditions that Chadwick's spectre would find around a million people in Dar es Salaam living in today. These are the people who have migrated from their rural communities into the unplanned settlements of Tanzania's largest city.

ENVIRONMENTAL HEALTH

This year, EHOs will qualify with Tanzania's first BSc environmental health degree, after a 27-year battle to get academic recognition for the profession. There are 450 diploma-qualified EHOs in the country. But environmental health has always been considered a Cinderella profession because it lacked the kudos of a degree qualification. EHOs graduating from Muhimbili University in Dar es Salaam will now become part of a public health vanguard influencing national policy and offering environmental health education at every level of society. The Northern Ireland Centre, supported by the CIEH, raised funds for a library to support the degree course.

HISTORY

There are over 3 million people now living in Dar es Salaam which, until the mid-19th century, was a small fishing village. In the 1860s, the Sultan of Zanzibar decided to develop the area's inland harbour into a port and trading centre. It subsequently became the seat of colonial German government in 1891 and then, from 1919 to 1961, the capital of British-administered Tanganyika. Since Tanzania gained independence in 1962 the city has remained the undisputed political and economic capital despite the legislature and official seat of government transferring to Dodoma in 1973.

DISEASE

Malaria is the biggest killer in Tanzania. Out of a population of 33.5 million, there are 16 million reported cases of the disease annually. Up to 15 per cent of childhood deaths are due to malaria, which also accounts for 6 per cent of all hospital deaths. Eight and a half million live in urban areas with the remaining 25 million living in around 10,000 rural villages. Other killers are cholera, HIV and diarrhoeal diseases, with life expectancy in parts of Tanzania as low as 37. One-in-five children die by the age of five from preventable disease.

HOUSING IN DAR ES SALAAM

For up to a third of the population, home is in unplanned settlements such as those that have grown up along Nyere Road, running from the city centre to the airport. It is here that most of the 300,000 rural poor who migrate into Dar es Salaam each year end up. And it is here that the new breed of EHOs will need to focus their attention to stem the spread of disease, through education and public health initiatives.

The settlements are overcrowded and offer very poor water supplies and sanitation. Houses are made from whatever is available. Many are traditional building designs using wood, daub with grass roofs. Others use concrete blocks, corrugated iron and whatever is at hand. The main obstacles to preventing the spread of disease are poverty and the unplanned way the settlements have grown.

Petty trading and low-level employment are the main sources of income. Houses are put up wherever there is space, so roads become blocked, shallow wells get dug next to pit latrines and waste water flows onto footpaths. Access by open refuse trucks is often impossible when the roads are churned up during the rains, so solid waste ends up crudely dumped on open land. Over 95 per cent of all roads have no storm water drainage so they quickly become impassable or pockmarked with puddles of water, ideal breeding grounds for mosquitoes.

But it would be a mistake to characterise the city solely by its slums. Dar es Salaam is architecturally diverse, made up of colonial housing from the German and British eras, an area of small shops and workshops populated by Hindus, Sikhs and Shia Muslims and a large area to the north, of European style housing used by government or state officials. The most recent figures show that around a quarter of houses have piped water and over a third have mains electricity. However, fewer than 5 per cent of residents are connected to a central sewer network, with 70 per cent using latrines.

SANITATION AND DRAINAGE

Public health initiatives will need to centre on improving sanitation. Most pit latrines are crude and makeshift. Over half have no roof or pit cover, a third have no doors and nearly all lack a vent pipe. Most latrines are shared, overused and fill up quickly, especially during the rainy season when the water table is high. Residents often avoid the costs of emptying them by taking advantage of flooding to flush them out. The lack of proper roads often means that, in the settlements, they are difficult to empty as motor traffic cannot get through.

Research in Lesotho, South Africa, has shown that the introduction of national design standards for latrines, along with public health campaigns explaining the benefits of good sanitation, will go some way to improving standards. The population also need to be sold the idea of ventilated improved pit latrines (Vips) as desirable, modern and convenient. The Tanzanian government's attitude towards Vips has so far been lukewarm, but NGOs are making efforts to popularise them.

Most of the unplanned settlements are on low lying marshy land that floods once or twice a year. The flat terrain makes drainage difficult. Polluted stagnant water is a major cause of disease and death, especially as there are few animals for mosquitoes to feed on, making the spread of malaria among the population very intense.

Malaria is endemic all year round in Dar es Salaam. As a result, people suffer repeated infections and adults build up immunity. Pregnant women and children, however, are very vulnerable to the disease, with childhood mortality exceeding 10 per cent. Resistance to drugs is one of the most serious problems.

Improved drainage and methods of dealing with waste are the most effective ways to stem the spread of malaria. Reducing the mosquitoes' breeding sources is key. But this will need a heavy injection of cash, which is in short supply, even though in the long run it would be cheaper than sustaining existing control methods.

Meanwhile, the public health community relies on other methods. The use of insect growth regulators (LGRS) like pyroproxifen is increasing, along with expanded polystyrene beads placed in confined spaces to suffocate the larvae, and insecticide impregnated insect nets. LGRS are particularly useful in areas where crops are farmed or where there are animals as they are nontoxic. Swamps are being drained or being stocked with fish, invertebrate or predators that feed on mosquito larvae. Throughout the year, workers keep to a vector control calendar, starting in January when drains are cleaned in preparation for the coming rains and ending in the late dry season when areas around residential housing are checked for breeding sites.

The national malaria medium-term strategy for 2002/07 aims to ensure that 60 per cent of children suffering from malaria receive treatment within 24 hours, up from 19 per cent today. The government wants 80 per cent of children to receive proper treatment at health facilities. Using a voucher system, the strategy also aims to ensure that 60 per cent of children and pregnant women will sleep under insecticide impregnated bed nets by 2007.

SAFE WATER

Demand for water in Dar es Salaam far outstrips supply, with two- thirds of the 90 million litres needed daily coming from pumped supplies. Last August, responsibility for pumped water was transferred from government to a private company. The government had been plagued by financial and management problems, leaving the way open for City Water Services Ltd, which has been tasked with supplying water to unserviced areas and improving efficiency. Plans are in place to install 173,000 water meters into homes and businesses, to reduce the amount of people illegally connected to the supply network, and expand the existing network by 500km over the next five years. Funding is being provided by the African Development Bank, the World Bank and the European Investment Bank. Polluted water supplied by leaking distribution pipes and shallow wells are considered the main sources of cholera and diarrhoeal disease.

URBAN PLANNING

A common view among officials is that the illegal land occupation leading to unplanned settlements in Dar es Salaam has blocked provision of drains and water supplies to these communities. In Tanzania, in a throwback to colonialism, land is vested in the president. Settlers who lose their homes, due to work on the public health infrastructure, will only be paid for the value of the building materials they used, not the land. This effectively makes them homeless as they have no money to find alternative housing.

However, the government is shifting its attitude towards the legality of the settlement areas. A new drainage project on the Nyere road, involving the demolition of homes, is focusing on community consultation and offers of rehousing to settlers. It is hoped this new approach will lead to the cooperation of settler communities where homes must be destroyed to make way for a new public health infrastructure.

Bill Page, EHO from Newham LBC, took a month of unpaid leave last October to investigate how environmental health interventions could improve public health in the settlement communities of Dar es Salaam. The above is a summary of an independent report of findings he produced at the invitation of staff at Muhimbili University.

EHJ is starting a series of articles on international public health initiatives. Next month, how Cuba tackles private housing standards.