1992-93 sabbatical exchange visit to the United Kingdom.

To list environmental health programs conducted in the United Kingdom would be redundant as they are nearly the same as those conducted in the United States. Them are twists to methodology and/or complexities that I found fascinating. I have described these points of intrigue below.

Professionalism

The British environmental health officers (EHOs) seem to exude professionalism. Perhaps some of this is influenced by their more formal mode of dress, which wa one of my first observations. Suits were standard attire among the EHOs, except at Milford Haven Port Authority where because of the nature of the job, sweater replaced dress jackets. I have the impression that the EHOs consider themselves to be "professionals." From my observations he/she is treated as a professional by not only the district councilors, but also by the public at large. From discussions with my peers, most American health environmentalists, though trained and experienced, feel they are viewed as having a "vocation" rather tha a "profession."

Perhaps the fact that a British EHO enters the profession educated and trained, rather than requiring training, accounts for a better, more professional attitude. As environmental health degrees in the United States do not require lengthy residencies, a health environmentalist will not emerge as fully prepare as the EHO, who serves at least one year of supervised field service.

The fact that a standard has been set by the profession and upheld by the government precluding the hiring of a non-certified EHO at the EHO level adds t that professionalism.

Professional Preparation

The amount of preparation required in the United Kingdom to become an environmental health officer is intriguing. Each officer is credentialed by the Institute of Environmental Health Officers. Educational background is of prime concern as a degree from an IEHO-accredited institution is required. This may involve three years of classroom study and one year of residency in a district office. The candidate may be supported by the district throughout the four years, or he/she may be supported by the district only during his/her residency I have not been able to ascertain the requirements after graduation for remaining with the district supporting one's education. I was amazed that one district employed a person with a doctorate in food technology as an environmental health technician because of his inability to meet the specific educational requirements of an EHO.

The concept of hiring only persons with an environmental health degree seems foreign to us in the United States. If employment advertisements for health environmentalists are any indication, Kentucky, as well as many other states, requires only 24 semester hours in the biological sciences to qualify for such position. Effective July 1, 1993, Kentucky legislation requires a person entering the profession to become registered by the state within a year of employment. Before passage could be gained for this law, conditions of recruitment which would have required a degree in environmental health or equivalent to qualify for employment were watered down to only a 24-hour requirement.

Multiplicity of Disciplines

I was surprised by the multiplicity of disciplines that the British EHO must master. I do not think that many can practice in all disciplines for which they have been trained, but having received three years of broad-based training may account for their ability to switch gears rapidly. I was surprised to see so many functions, including ambient sampling and meat inspection, being performed on the local level as is the case in the United Kingdom.

Mix of the Old and the New

I was impressed with the age of things in the United Kingdom, buildings of such awesome size as Durham Cathedral and Westminster Abbey. It is hard to imagine the work required to complete such a structure as Durham Cathedral in the eight and ninth centuries. Yet not only is it standing, it is used daily. In Swansea walked down the street observing a crumbling castle situated alongside a modern glass skyscraper. I attended services in churches that were built in the twelft century. Though upkeep and comfort are not always economical, these buildings are commonplace in the United Kingdom.

Use of Mass Transit - Trains

I became a quick convert to trains and subways ("tubes" in London). Commuting b train four weeks in the United Kingdom made me wish the United States had a comprehensive network of passenger trains--good for the environment, good for the body. It became very relaxing to listen to the clack of the rail and to be able to converse with complete strangers. I found that being from the United States spawned many questions. Some people had heard of Kentucky, especially th Kentucky Derby, which is spelled the same but pronounced "darby" in the United Kingdom. One was dismayed to learn that Jack Daniels is a Tennessee sour mash whiskey, not a Kentucky sipping bourbon. Like most Americans, the British peopl I talked with thought environmental health officers were "environmentalists," people out demonstrating against destruction of the rain forests. Though very proud of my personal membership in environmental preservation support groups, there is a stigma to the term "environmentalist" that tends to east a negative into some conversations.

Contract for Service

Some discussions with EHOs concerned the possibility of contracting for environmental health service by bid process. Some thought the district councils might be receptive. I think this idea crosses the minds of many environmental health professionals today. How can we feel comfortable watching the privatization of services for penal institutions, municipal sewage treatment plants, garbage collection, and landfills. I dare not ask, "Are we next?"

Reorganization of EEC Membership

Without listing specific changes in sanitation requirements resulting from the United Kingdom's membership in the European Economic Community (EEC), I sensed that these changes seem to be causing feelings of distrust concerning product imports, and, indication that changes to meet standards are excessively costly and often unnecessary. In order to equate what impact the EEC standards would have on the United Kingdom, I have been trying to think in terms of what it would be like if all our laws and interpretations came from our federal government. As my son is prone to saying, "Awesome!"

Absence of Medical Health Officer

Since 1974 British environmental health programs have functioned outside the public health department, an institution that no longer exists as an independen entity. The medical functions of health departments have been absorbed into the national healthcare system. Environmental health programs function as an independent function of the district council. The physician, as contracted by the environmental health program, is contacted on an "as needed basis" by the EHO and is essentially considered a resource in his performance of disease investigations.

With the extensive training of the modern EHO, it is rarely necessary to call the medical practitioner regarding the epidemiology of foodborne illnesses nor for most other environmentally related communicable diseases, such as Hepatitis A. The physician is considered necessary for prescribing certain test procedure and interpretation of such, as well as more esoteric determinations concerning symptoms of cancers and organ damage, as might be environmentally related.

The structure in Kentucky could easily head in that same direction. Today only few medical health officers serve as administrative heads of departments. The trend for the past 20 years has been to replace physicians with administrators. Although no official actions by the state of Kentucky have been taken that indicate a trend in creating a separate environmental health department nor of incorporating environmental health programs into existing agencies, such as our Department of Agriculture or Cabinet for Natural Resources, movement toward universal healthcare reform has left many of our health environmentalists wondering if they will fit in the emerging system. After 20 years of practice, the British EHO seems very comfortable working outside the administrative purview of the medical community.

Computerization 

Both British and American environmental health officials suffer from a lack of computerization. Both suffer from inconsistency of programming and system incompatibilities. Each of the eight authorities I visited had a computer system, but none the same one. Each system was specifically tailored by that district's need. As in Kentucky I felt that most considered themselves to be computer illiterate. Traveling from one district to the next, I encountered different degrees of enthusiasm. Almost consistently the supervisors were anxious to gather data, but field staff saw the machines as a method to check o their performance. Local district mainframes dominated the type of systems used In those districts where true computers were observed, they were on the supervisor's desk. Districts varied as to whether information was accessible vi an EHO's personal terminal or indirectly from the terminal via printed reports from the clerical staff. Informational input into terminals varied by district. Networking on a national basis is not in place except that Milford Haven Port Authority had the capability to contact any other port health authority.

In Kentucky each local health department is on-line 24 hours per day, thus enabling each department to transmit to any other department and to the state agencies. Based on the FDA's early computerized Sanitation Program Information Filing system, Kentucky now utilizes an extremely sophisticated 24-hour per day on-line computerized information system. Though it lacks the ability to be specifically tailored locally, it is a start in comprehensive programming covering our full complement of programs. As in the United Kingdom, the United States has no national computer program being used by all states. Nationally there are software and call-ups available to those with computers in their office, but not widely publicized and not tied to Kentucky's mainframes.

The same type of situation exists for British and U.S. environmental health officials as to degrees of equipment usage. For example, on a person by person basis in my Pike County office the degree of terminal usage varies from "not at all" to "comprehensive" depending on that particular individual's interest and familiarity with computers. Access is also dependent upon the director's attitude and/or budget. Unless adequate funding is made available to equip individuals with computer equipment and adequate time for on the job computer education, low usage by the environmental profession will continue.

Hand-held computers are used for food control programs in both countries in ver specific localities, and I confess envy for those that have reached this level of computerization. Although I have seen demonstrations of these units, I confess that I have not seen them in actual field use. I was told that at least one district in London was so equipped; however, not knowing which, I was unabl to secure data as to improvement in program efficiency and effectiveness.

Governmental Structure

The bureaucratic structure of the United Kingdom consists of a national level and essentially two local levels, counties and districts. Environmental health programs are a function of each district council, as are housing and planning. Laws passed by Parliament are utilized throughout the country. I was not made aware of any locally adopted ordinances, although methodologies for compliance varied. For example, the collection of garbage household solid waste is a function of local government, a service that by national law is mandated to the local government; however, the district council can make the determination as t how it is done. To illustrate this point, I attended one district council meeting where a long and heated debate ensued regarding whether to continue collecting garbage in black plastic bags or switch to wheeled bins.

I found the forum extremely interesting and compared the proceedings to Pike County's fiscal court proceedings. I was surprised to learn that although the press and the general public are invited and encouraged to attend, they are not allowed to express their opinions. Debate and discussion are confined to the members of the council and program directors who are present to report to and t advise the council members. I was told, perhaps not so jokingly, that if the public were allowed to express their opinions along with those of the 60 member of the council, the meetings could last an eternity and agreement might never b reached. With only the county judge executive and six magistrates and the publi speaking, some of our fiscal court meetings go on forever and often decisions are tabled forever. ("Tabled" is a term that should not be taken lightly. In England one might be advised that he should not suggest tabling the subject unless he is ready to discuss it at length. To table means "to put it on the table to discuss," not postpone discussion as we in the U.S. use the term.)

Food Protection

HACCP is being touted loudly in both countries as the method of future inspections. I am one of those touting the concept, but how to find the require time to conduct such thorough inspections is a question with which I have been trying to cope. The British may have at least a partial solution, that of determining the frequency of inspection by assessing the degree of risk that a particular establishment presents. This system requires that the EHO answers a series of questions concerning each establishment as to the following criteria: 1. the potential hazard of the foods handled; 2. the methods of processing; 3. the consumers at risk; 4. the level of compliance; and 5. the confidence in management/control systems.

Each of these categories have specific, objective rationale excluding (5), whic gives the EHO an opportunity to subjectively enter "gut-feelings" concerning a particular establishment. From this review process each establishment is subsequently assigned a time period ranging from six months to five years between inspections.

I had the opportunity to accompany British EHOs to several food establishments. The first aspect of inspection that impressed me was the professional mode of operation. First, I had been told that the British EHO dressed as a professiona at all times, males wearing a jacket and tie as standard attire and females in standard business dress. I had not been briefed as to the protective clothing o the inspector during the process. Almost without fail when we went beyond the office of any food establishment from small pubs to airline caterers to Maynard's, a manufacturer of hand finished desserts, a regimen of actions was i order. We first introduced ourselves, giving the purpose of the visit and askin management-related questions. That initial conversation was at times conducted while having a cup of tea or coffee with the manager or owner. My first thought were of surprise, having been indoctrinated into a concept that taking so much as a cup of coffee was morally, if not legally wrong. I may modify my thinking about accepting a cup of coffee and perhaps just a small slice of chocolate fudge brownie cheesecake, as this process may produce a natural flow of conversation. In the time that it takes to drink that cup of tea, one can ask several questions and obtain much information. After the introductions, the nex step was to gear up, removing rings, watches, and jackets and donning inspectio whites and hairnets. If the inspector wears a beard, a net or face mask is provided. In some cases we also donned white wellington style boots.

Inspections were quite thorough, the influence of HACCP apparent, with the EHO observing processes and practices more particularly than the condition of floor coverings. This mode of dress on the county level in Kentucky is not practiced; however, for three years I conducted FDA-State contract food manufacturing and storage facility inspections during which we dressed in lab coats and caps. Dressing for inspection work in this manner certainly makes for a professional appearance and sets an example for industry. I also noted with pleasure that upon entry to any food preparation area the EHOs washed their hands before beginning their work, another practice which sets an example for the workers that see them do this.

After the inspection was concluded the EHO informed the owner of the items of "contravention" and discussed items of good hygiene practice. I was surprised that forms did not change hands at that time. I learned that formats had to be followed, these varying from district to district, but with the use of word processors in most eases. The EHO wrote the details of the specific violation into standard paragraphs, which was then returned to the owner as a report or a a notice. I was told that certain districts have an abbreviated process incorporating a form that can be issued at the time of inspection, and at least one in London as previously mentioned uses hand-held computers that generate th forms instead of having to backtrack later. Working on the local level in Kentucky our food premise inspections are standardized and normally very short in narrative, using Kentucky's version of FDA's 44-item inspection sheet. Most of the EHOs were very interested in the fact that we assign rating scores, usin these scores to determine scheduled times for compliance inspections, and that we can order closure if the score is low enough. In the United Kingdom the EHO may issue an emergency prohibition notice if conditions warrant. Once issued th notice must be filed and proven in magistrate within three days. If unproven, the district must pay the establishment retribution.

Environmental Health Education

Several local competition schemes were related during my visit, most concerning food hygiene training, but one caught my attention as unique as it involved not only a good hygiene inspection rating history, but also the completion of a six hour basic food safety course, 30% of the tables designated as non-smoking, and a range of nutritionally sound foods on the menu. Appropriately named the "Heartbeat Award," the administration of the program involves the EHO, a nutritionist, and a health educator working in accordance. The program is completely voluntary on the part of management but is gaining acceptance becaus the public appears to be responding in a positive manner to those establishment that have the "award" certificate on the wall and the decals in the window. The government furnishes stickers for the menus and does routine media releases.

Other programs of major proportions include national cleanup and local district cleanup. The British equivalent of our "Keep America Beautiful" program is the "Keep Britain Tidy" campaign.

I was impressed with the proliferation of pamphlets that are made available to the public. I managed to ship single copies of many of these home; however, the postage meter tipped the maximum three times during my stay and I have only a sampling of what I saw. To exemplify, the public has access to such informational pamphlets as, "Safe Lunch Boxes," "Stay Safe" (temperature controls), "Government Guide to Food Safety," "The New Microwave Labels," "Abou Food Additives," "Understanding Food Labels," "Best Before and Use By," and on and on concerning food protection.

Equally vocal via pamphlets are the other sundry of programs as exemplified by such titles as "Radon in Houses," Smoking in Public Places," "Safety with Lifting and Carrying," "Bothered by Noise," "Planning: A Guide for Householders," "Is the Water You Drink Really Safe," "Abandoned Vehicles," "The Fox," "Green Rights and Responsibilities," "You and the Ozone Layer," and "Wast Not!"

Especially pleasing was the presence of two very informative books concerning the EHO and services: offered by the EHO. Public education through the dissemination of pamphlets and brochures is an aspect of the job that the British are taking seriously. These materials were observed in waiting areas of all the councils. In new health departments in Kentucky I have observed that areas of main lobbies have no wall racks for pamphlets. I do not know if Hill-Burton funded health department buildings were required to have the pamphlet holders on the wall or if the trend during the era of these buildings was to provide the same, but every one I can recall visiting had that set aside area, but no more. I know there is no shortage of public relations materials in the U.S., but getting the information into the hands of the general public is the main purpose. If left stored in our government's publishing clearinghouse i Pueblo, Colorado, cases of pamphlets will do nothing to improve the quality of environmental health in our country.

Conclusion

With the 1974 reorganization, the EHO was left without the health officer authority administering his job. I can not speak with any degree of authority concerning this issue, except to say that the absence of the medical supervisor did not seem to be of concern to the EHOs. In general conversations EHOs reported good cooperative efforts between the two professions. Perhaps a partnership between the two professions would be the ideal situation.

I favor the British use of the term, "Environmental Health Officer" rather than "Environmental Health Specialist" in that people still relate to medical health officers of traditional local health departments.

My month in the United Kingdom was quite fascinating to me in many ways. The people I encountered were extremely helpful and polite. The EHOs were very professional and polished.

EHOs relate more to local section groups near their districts than to London-centered activities of IEHO. They are pleased with the quality of publications but would like to see more interest by the IEHO office for local participation opportunities by EHOs in outer fringes of the country. I think that similar thoughts would be expressed by American health environmentalists. Most would say that they are more involved with the activities of state affiliates than with NEHA. In the U.S., NEHA is addressing this concern by planning several one day regional conferences, rather than a large mid-year conference.

I returned from the United Kingdom with several ideas that I can incorporate into the everyday workings of my department. Of special interest to me was the proliferation of public relations materials and ideas for a health promotion (Heartbeat Award) that I have already begun to plan with our health educator an nutritionist.

I would be remiss if I failed to mention the social and cultural benefits that derived from this experience. The opportunity to become acquainted with EHOs an their families after working hours and to become involved in their social lives were experiences that I would not have had if I had visited as a tourist, or ha I chosen to spend my nights in hotel rooms. Dancing to Welsh and Scottish folk music, touring Durham Cathedral and Hampton Court, experiencing evenings in English pubs without the stigma of being a tourist are memories that I will never be able to replicate. Professionally and personally this experience was extremely rewarding and one I would recommend to any interested environmental health professional.

Gary Coleman, R.E.H.S., M.S.E.H., 461 Lakeshore Drive, Lexington, KY 40502