VSO promotes education in Namibia to heal health inequalities left by apartheid system

Namibia gained independence from South Africa in 1990. Huge inequalities in housing, health care and education are a legacy left by the apartheid system and it is estimated that 40 per cent of the population still live in absolute poverty. The Namibian government's policy is to redress these imbalances - in the health service this means an emphasis on primary health care, a system which focuses on prevention rather than just the curative system favoured by the old regime. Environmental health fits into this structure.
My post is based in the coastal district of Swakopmund and the region of Erongo, an area of desert. Sanitation provision for rural communities and infectious disease control in urban areas and squatter settlements are the main elements of the job.

Community involvement in sanitation projects is an integral part of the ministry of health's philosophy. I have been involved in organising transport, labour and materials for building seven demonstration VIP (ventilated improved pit) latrines in rural community. Before the project began, I carried out community mobilisation, which included health education to raise awareness of the need for proper sanitation. A Food for Work scheme added an extra incentive for participation. The community then helped with the construction of the latrines and this gave them an interest in building their own.

URBAN DRIFT
The coastal settlements attract a large migrant population who seek jobs in mining, construction, tourism and fishing. Many people forming this "urban drift" from rural areas end up in squatter settlements on the edge of towns, or in makeshift shelters of corrugated iron sheets in the backyards of existing dwellings. Overcrowding and malnutrition are common, facilitating the spread of tuberculosis (TB) and poor hygiene, leading to high incidences of dysentery and other diarrhoeal diseases.

The role of environmental health professionals in TB control is to trace the close contacts of patients who visit the TB clinic in Mondesa township of Swakopmund. For this purpose I have been involved in setting up a team which carries out home visits to assess the housing situation and educate the household members on factors which encourage the persistence and spread of TB, such as overcrowding and poor ventilation. They are also advised to visit the TB clinic for a medical check. Patients have to take a cocktail of drugs every day under a scheme known as Directly Observed Therapy (DOTS). Those who default on treatment are traced by environmental health personnel. Defaulting is a serious problem as it leads to the growth of drug-resistant strains of bacteria.

Susceptibility to TB is enhanced by HIV infection. The HIV infection rate is estimated to be at least 20 per cent of the population age group 15-49. Erongo is part of a major trade route and this facilitates the spread of the virus. Other reasons for the rapid spread of the virus are deeply rooted in culture and difficult to tackle, with widespread denial of the problem. With my colleagues I organised visits to the local community to talk to people, hand out information in different ethnic languages and invite their comments on the subject of HIV/Aids. The issues raised were then addressed using a local school drama group and local band to take the message back to the community.

I also carry out routine inspections, give food hygiene talks and help with infection control training at the hospital. The work is varied and gives an opportunity to make a difference.
For information contact Jane Quayle, VSO, 317 Putney Bridge Road, London SW15 2PN. Tel: 0208 7807268. E-mail: jquayle@vso.org.uk

The Water for Kids trip in October gave 21 EHOs first-hand experience of hardship and public health problems in a developing country. David Clapham opens his diary of the trip to EHJ

Week 1
Friday 4:00am, 21 environmental health people set off from seven different UK airports. Despite delays and missing luggage, after 20 hours flying, we all arrived safely in Lima. The rooms in the hotel were basic, small and clean. However all the metalwork connected to the showers was live, making getting in and out a delicate operation.

Saturday This was the only day in Lima with time to sightsee. I had a meeting with Water for Kids´ Peruvian partners OACA and then went with them to eat Perihuela - a delicious spicy seafood soup.

Sunday Out to the village of Quebrada Verde. This is where Water for Kids has been working to get a water supply put in. At last it is finished. The pump is working, the well dug, the pipes laid and the water flowing. At the well, which has its own guard in case someone wants to steal the pump, we had an opening ceremony. A bottle of local "champagne" was smashed with a spanner against the building.

Monday Today we went into the Andes to start our placements and to work on the Environmental Health Action Plan for the province of Huancayo. The bus journey took about eight hours, with spectacular scenery and even more spectacular mining camps spewing pollution into the rivers and the air. We stopped in the snow to get out at the highest point of the Andes Railway (the highest in the world). By this time it was getting a little hard to breathe due to the rarified atmosphere. We arrived in Huancayo and were taken for a meal in a restaurant with sawdust on the floor, guinea pig on the menu and cocoa leaf tea to drink to counteract altitude sickness.

Tuesday Attended a seminar at the complex where we are staying to plan the next two weeks´ activity and meet our Peruvian colleagues.

Wednesday A day of visits to look at the problems. One group visited a rich school - quite like the UK - and a poor one, which had "absolutely foul toilets, broken windows and the roof was falling in". Another group went out with the Ecological Police to a meat, fish, vegetable and live animal market. They were shown round by the market inspector, a qualified vet. He mainly checked the meat, as Huancayo has problems with beef and pig tape worm, TB, etc. After that they went to a poor hospital where treatment costs 60 pence a session. Infant mortality in Huancayo is 120 deaths before the age of one per 1000 births (it is 6.1 in the UK). Life expectancy is 40 to 50. The doctor said the biggest dificulty was gastro-intestinal disease, which brings 80 cases per day to his hospital. When asked what the major public health problem was, he replied "lack of education".
Another group went to the local water treatment plant. The water company was particularly interested in leakage reduction (50 per cent of water is wasted). Out of a city of 350,000 people, over 100,000 are not supplied with water, although there are a lot of illegal connections. The water-works was overloaded, producing twice as much water as is safe.
The final group looked at pollution problems, going with the Ecological Police to visit a heavily polluting textile factory. The waste went straight into the river where children were playing, despite the fact that the river had turned blue from the dye. In the afternoon they went to a tannery which also spewed waste into the river, but the owner wouldn´t let them in. Finally they went to a large, badly-run rubbish dump with pigs (and their tapeworms) wandering all over it.

Thursday More visits to schools, factories, markets, waste dumps, open sewers and polluted land and water. Everyone is glad to see the real problems here, rather than just hear about them.

Week 2
Friday, Saturday, Sunday Early on Friday everyone went to the jungle for a three-day break. The journey there and back (about 12 hours) was hair-raising not only because the bus was clapped out and the road dangerous but also, due to recent guerrilla problems, there was a police escort all the way. Saturday was spent in and around Santipo, a small frontier town that was having its annual fiesta day.

Monday Back in Huancayo for more visits and work on group projects. All the EHOs are getting on very well with the Peruvian members of their group.

Tuesday Last few visits and meetings. Some people lectured schoolchildren about hygiene and environmental awareness. Because of our visit, one of the rich schools has linked up with a very poor school and will help towards its finances and teaching. At night we had a big party in the Town Hall. We taught the assembled Peruvians Scottish Country Dancing. The Peruvians then taught us the Huancayo Shuffle and sang to us. We replied by teaching them the hokey-cokey - a true cultural exchange.

Wednesday The final seminar day where the "joint reports" were presented. There were a few speeches to close the event and to thank everyone for their hard work. We will do a final report when we get back to the UK and send it to various agencies in Peru. We were all impressed with the friendliness and helpfulness of our Peruvian co-workers.

Thursday Back to Lima on the overnight bus. For some people it was their last day in Peru, but most went to Machu Pichu and the Inca Trail for a week's holiday. I had a meeting with OACA to discuss the success of the visit, plans for Huancayo, and new projects for Water for Kids. These included a bakery for a small school, a jam-making plan for another school and some toilets in a squatter village.

My grateful thanks go to all those who came for their support, willingness to help when asked, good humour in the face of adversity (mainly food poisoning) and Scottish dancing skills.

Water for Kids will be organising another short field trip to Peru in the future. If you are interested in going along, please call David Clapham on 01274 754381.

In Lithuania people really only think about health when they are sick.
We have some similar health problems to the UK - half of men smoke and 15 per cent of women, but the percentage is higher among young girls.
We have worse problems with alcohol than Britain - especially in rural villages. Vodka used to be very cheap, and bad wine. We also have a lot of drug users now, and Lithuania has the highest rate of suicides in Europe. As many as 80 per cent of those who kill themselves are drunk.
The crime situation is serious, I have been surprised by how quiet homeless people and beggars are in England; in Lithuania they are strong people who demand money forcefully.
As for the environment, we have major problems with transport. When all the walls came down in 1990, many cars came through from the West. In 1990 we had one car per 50 people, now we have one car per three, with more than 1 million cars registered a year. These cars are all old, so there are problems with pollution and noise and now we must think about changing the traffic system if we want to have a healthy nation.
A second major problem is food. After independence, products from the West flooded in, but not always good products. Now we have a strong system of control, but if we don't change business minds then control alone won't do it.
The country is still poor. People buy cheap products in markets and shops, often illegally, because they are cheaper.
Our water is all from underground sources. It is mostly good but we have two problems. Firstly there is a lot of iron, which turns water brown, and it is too expensive to treat. The second is fluoride, two regions out of three have too much fluoride in the water. There are also microbiological problems in villages where they use wells.
As for waste, at the moment about 90/95 per cent goes to landfill. There is no other way to deal with it. Recycling is only just beginning in big towns.
In Lithuania we do not have specialists such as EHOs, so it was interesting for me to see how they work in England.
During the month I spent in England I had meetings with the Department of Health, Department of Environment, Transport and the Regions, Local Government Association, Leicester Environmental Health Institute and Sheffield local and health authorities. I also met people from the Environment Agency, Greenwich University, and private companies.

STRONG SERVICE
The capital of Lithuania, where I live, has a population of 600,000 - Sheffield has 500,000, so they are comparable. But in Sheffield the service for environment and health has 40 people, in Vilnius it only has six or seven.

What was interesting in England is that it has a good national system which works like a pyramid.
The Government prepares strategy, the agencies under the ministries make regulations and do some enforcement, but the big problems are dealt with at local level through local enforcement. In Lithuania we do not have such a strong service in local authorities.
I am an epidemiologist by profession and I work in the ministry of health as head of the public health division. Unlike England, we have vertical system. There are nine institutions at state level, covering: nutrition, radiation, health and safety, accidents, environmental medicine, health education, Aids, communicable disease, public health and environmental health.
We have 10 public health centres with environmental health responsibilities, but in local authorities only a few people are responsible for health/environment and they all work in different departments.
I work 12 hours a day because we have so many problems, and since independence we have had to change all the laws and regulations.
But changing laws is easier than changing minds. We won independence in one day, but changing how people live is very difficult. They used to do as they were told, now they have to think what to do. I want to see more enforcement functions pass to local level.
On my return I will recommend change and also recommend the licensing of professionals as you have in England, which at the moment is done by universities.
I will try to make a difference, but ultimately these changes must be made at government level.
The English Government is much more integrated on these matters. I was very impressed by the White Paper Our Healthier Nation: Saving Lives, and to see that it had the signatures of a large group of ministers. In my country only one minister is responsible. When we prepared the National Environmental Health Action Plan for Lithuania we took comments from other ministries but I think they blocked many ideas. The problem is that there are financial pressures and they have other priorities.
We have to have a stronger health system, we have to integrate health and environment and do it more professionally and practically, not just talk about it.