Where there's hope, there's change. (International Perspectives).
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 diarrhea.
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 U.N. figures for 1999, 8 percent 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 infection, and in some urban areas up to 30 percent of pregnant women are diagnosed as 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. Focusing on Tanzania's approach to public health and the development of the environmental health profession makes it 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 U.K. 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, 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 organize the training of skills, but the deployment of workers is 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 have had their price. And one of the most disruptive results of the reform period has been a freeze on the employment of environmental health officers (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.
According to Dr. Upunda, however, 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."
This talk of contracts and private EHOs, only 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 15 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 recognized 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, noncommunicable diseases, including cancer, are going up fast." Tanzania currently has around 1,500 health assistants, and the government would ideally like to see that number 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 of water quality. Health and safety and environmental protection tend to be more the concern of large Western companies, with Tanzanian EHOs concentrating on frontline disease prevention without specializing in other fields. It is recognized that the biggest problem facing EHOs in rural areas is transport. With, in some cases, thousands of kilometers 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 that everyone shares one belief: that education will be Tanzania's salvation. And it is in part due to the library appeal launched by former Chartered Institute of Environmental Health (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 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 after 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 that 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 [pounds sterling]130 ($206) a year, it is recognized 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.
A visit to the slums of Dar es Salaam makes it 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 percent 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 a focus on city planning will resolve the overcrowding that is causing social problems and disease.
"You must instill 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 that property has a value and people know that this is their plot."
Poverty also affects the EHO's ability to enforce the law. Renatus Mashauri, a Tanzanian EHO and lecturer who has experienced environmental health in the United Kingdom, explains: "Even though we are enforcing a minimum legal standard, it is still costly for businesses that 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," adds Mr. Mashauri. "You can't put these people in jail, or their families will be destroyed."
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. The assignment of pharmaceutical control to the same agency as food hygiene is in part due to the lack of degree status EHOs have suffered from 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. If this one problem could be solved, most of the diseases that 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.
(Adapted, with permission, from the Environmental Health Journal, the official journal of the Chartered Institute of Environmental Health, Vol. 110/07, July 2002. The Environmental Health Journal can be found online at http://www.ehj-online.com.)
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|Publication:||Journal of Environmental Health|
|Date:||Apr 1, 2003|
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