EHJ July 2002, pages 206-209 Following a recent enlightening visit to Tanzania, Stuart Spear reports on the recent government changes that are set to address the country's problems with regard to poverty and health

Turning left off the Nyere road, the main route between Dar es Salaam city centre and the airport, the ancient VW van - more rust than metal - bucks and weaves, slewing down 2ft deep craters that pock-mark the dirt track. Within moments of leaving the tarmac road you enter the slums of Dar es Salaam, home to 80 per cent of the city's 3m population, where a one-room house of cement blocks, rotting wood and rusting corrugated metal will house a family of eight. Shallow wells dug next to pit latrines are a source of contaminated water often used for washing, drinking and cooking.

It is in the slums of Tanzania's largest city that the grim statistics linked to one of the planet's poorest countries are rooted. The happy snapshot of laughing African children posing for the camera has a grotesque twist here. Two out of every 10 children will die before they are five years old from preventable diseases such as cholera, malaria and diarrhoea.

There are few old people in the city slums where life expectancy is 37, well below the national average of 45 calculated by the World Bank for 2000. Aids is driving life expectancy down. According to UN figures for 1999, 8 per cent of Tanzanians are HIV positive, but no one really knows the true grip the disease has on the country. There are indications that the figure is far higher.

Cervical cancer rates are on the rise, a sign of increasing infectivity, and in some urban areas up to 30 per cent of pregnant women are diagnosed HIV positive. But it would be a mistake to think of Tanzania as an aid-dependent country devoid of hope. Behind the images of disease, poverty and hopelessness so commonly associated with Africa lies a far more optimistic truth. By focusing on Tanzania's approach to public health and the development of the environmental health profession it is clear that Tanzania is a country capable of solving its own problems.

Over the past four years, the Tanzanian government has undergone a series of radical reforms that some believe the UK government would do well to emulate. The ruling Chama Cha Mapinduzi party has taken bold steps to relinquish power to local authorities in a bid to give the people what they ask for, rather than what the government thinks they need.

"In the past, the way it worked was that central government would tell the districts that 'we want this issue dealt with' and they would have to do it," explains Dr Gabriel Upunda, Tanzania's chief medical officer. "Now there are very few issues districts have to include in their health plans. For example, if they want to focus on the eradication of polio they include it in their district plan and there should then be a policy of bottom up planning to address the problem."

"The changes have meant we are now in a position where we can say to the districts that they should make their requirements known," he continues. "The Department of Health will organise the training of skills but the deployment of workers is now done at district level. Through the district plans we will learn to listen to the community, find out what the people want and then provide it for them."

But four years of upheaval has had its price. And one of the most disruptive results of the reform period has been a freeze on the employment of EHOs, which has meant that students taking the country's environmental health diploma course at Muhimbili University have been unable to find work. Meanwhile, Tanzania's 450 employed EHOs have been struggling with increasingly impossible workloads. Only health workers seconded from their districts and retraining as EHOs have been guaranteed employment at the end of the three-year course. However, according to Dr Upunda that is all in the past and he guarantees that all students on the diploma course and the new environmental health degree course, launched last year, will find employment.

"Health workers are being shifted away from central to local government," he says. "And by the time the students are finishing the degree course the situation will have changed. Contracts are the way we want to move [forward] with EHOs having renewable contracts for three to five years. We don't want to put an end to the public service career pathway, it's just that once staff have established a position they will still have to deliver."

To talk of contracts and private EHOs, just 17 years after Julius Nyerere, the architect of African socialism, stepped down as Tanzania's president is a sign of just how fast this country is changing. As Dr Upunda points out, it was only fifteen years ago that a Tanzanian government minister was almost fired for even suggesting that some health care costs should be paid for privately. Addressing public health is increasingly being recognised as essential if Tanzania's high mortality rate is to be reduced. And at the heart of the new health strategy is public health education, with trained health assistants operating at village level capable of educating people about disease control, hygiene and nutrition.

"Even more so now than ever before with the very high prevalence of HIV, good nutrition is very important to those who have been infected," adds Dr Upunda. "The pattern of disease has been changing. Although we have a lot of infectious diseases, non-communicable diseases including cancer are going up fast." Tanzania currently has around 1,500 health assistants, and the government would ideally like to see this rise to 8,000 - one for each village. But resources are limited and no one knows how soon this ambitious target can realistically be reached.

At local authority level the diploma-qualified EHOs are responsible for vaccinations, communicable disease control, waste management, food safety and monitoring water quality. Health and safety and environmental protection tend to be more the concern of large western companies, with Tanzanian EHOs concentrating on front-line disease prevention without specialising in other fields. It is recognised that the biggest problem facing EHOs in rural areas is transport. With, in some cases, thousands of kilometres to be covered and only one vehicle, access to remoter villages can become impossible.

This is the kind of issue that the new degree-qualified EHOs will have to grapple with. Graduating for the first time from Muhimbili University in 2004, they will be responsible for formulating public health policy on an equal footing with doctors and other health workers in the county's newly empowered regions, local authorities and health districts.

It is only by talking to Tanzanians, from slum dwellers to senior members of government, that it becomes apparent everyone shares the one belief that education will be Tanzania's salvation. And it is in part due to the library appeal, launched by former CIEH chairman, John McCandless and the Northern Ireland Centre and supported by the charity Water for Kids, that a 30-year dream for the profession to gain degree status became a reality last year.

The library, given to the Tanzania Health Officers Association (CHAMATA), is an example of the sort of sustainable aid that Tanzania needs more of. It provides a vital resource for the 24 students, who were selected from around 600 applicants for the first year of the degree course. Next year, 40 students will be enrolled with hopes for increasing student numbers year on year.

"Not being educated to degree level had a bad effect," explains Fabian Magoma, Tanzania's chief EHO and chair of CHAMATA, which has been campaigning since 1974 to have the diploma qualification upgraded. "If you put a group of professionals together such as EHOs, engineers, doctors and social scientists and they are all trained to their particular level, although your contribution is important, because the health officer is only trained to diploma level the other professions will not listen."

But, adds Mr Magoma, the education of the people in the villages and the slums is equally important. "We have a big problem with donor dependence which results in us trying to satisfy the interests of donor agencies rather than involving the people. An example is malaria control where impregnated mosquito nets are being given to the people. Although this is a good thing, it would be better if the people were more educated about malaria control so when they saw mosquito breeding sites they would be struck by it and demand change." There are no illusions that things will change overnight. With half the population living on less than £130 a year, it is recognised that poverty is at the heart of Tanzania's battle to improve its people's health. That is why there is such a desperate need to encourage inward investment and to develop the country's growing tourist trade.

And by visiting the slums of Dar es Salaam it is clear that just providing a public health structure is only a small part of the story. A migration from rural communities to the city, which is growing at 10 per cent a year, is putting an impossible strain on a city where most people are living without drains, roads or adequate housing. Nifukwa Mwakipake, senior tutor at the school of hygiene at Muhimbili University, believes that only by focusing on city planning will the overcrowding which is causing social problems and disease be resolved.

"You must instil in the people a sense of hope," he says. "You can't push them out of the slums because it is a violation of their human rights, so we need mapped out areas with some form of land ownership so property has a value and people know that this is their plot."

Poverty also impacts on the EHOs ability to enforce the law. Renatus Mashauri, a Tanzanian EHO and lecturer who has experienced environmental health in the UK, explains: "Even though we are enforcing a minimum legal standard it is still costly for businesses which are earning so little. In the end it is better for people to have work." The transient nature of business is also a problem. "In some areas of town people are well trained in food hygiene, but there are many people who cook at home and sell the food on the street. It is not easy because they will be gone tomorrow. You also have to be humane, you can't put these people in jail or their families will be destroyed," adds Mr Mashauri. The government is taking steps to tackle the food safety issue and legislation is currently going through parliament to set up a drug and food commission. Putting pharmaceutical control in the same agency as food hygiene is in part due to the lack of degree status EHOs have suffered until now. Ministers believe that food hygiene techniques will improve faster under the influence of the more academic pharmaceutical profession.

Probably the worst effect of poverty is that it deprives the poor of access to safe water, and if this one problem could be solved then most of the diseases which kill so many of Tanzania's children could be eliminated. While communities have access to deep wells, the country's crippling poverty often means that people cannot afford the few pennies it takes to pump the water to the surface. In the same way that Britain dealt with the scourge of disease and poverty in the 19th century through education and economic development, Tanzania is solving its own problems and EHOs are contributing to its journey to prosperity and health.