The environment and our health co-exist at all times

The environment and our health co-exist at all times, which underscores the reason for the continuous engagement and discussion about environmental issues around the globe in relation to our everyday health. According to Phoebe Thorpe (2016) “environmental health seems like an intersection of our environment and our health” (CDC, 2016). Consequently, having a good knowledge of the patterns of environmental and occupational hazards that can result to various health issues in many populations including industrialized settings and immediate environment help situates the concept of environmental health (CDC, 2016). These environmental or occupational hazards may be biological, chemical, radiological, physical or psychological in nature and of course, not usually environmentally friendly (CDC, 2016). So the everyday question that remains unanswered objectively with proper action is the demonstrable handling of environmental health issues in various localities, especially in Nigeria.

Similarly, since population health deals with health outcomes of a group of persons, including the distribution of those health outcomes within the group in their immediate environment, there is a need for continuous analysis of environmental health (UOR, 2018). It is therefore important to know more than ever before, that the assessments of population health status has continued to redefine public health ideology with key achievements in the field of public health relying on the insightful analysis of public health data, to determine who is at risk of disease in any location and group of persons (UOR, 2018).
In a recent release by WHO (2018) on public health, environmental and social determinants of health, “9 out of 10 persons are exposed to air pollution and breath in air with a high level of pollutants such as black carbon” (WHO, 2018). This further reiterates the emphasis on environmental health globally with WHO flagging the ‘Breathelife’ campaign and increasing collaboration with different countries on environmental health (WHO, 2018). Thus, considering the numerous environmental unfriendly circumstances that result in disease conditions, rapid and structured responses to the ever demanding health needs, the drive for development and promotion of health-friendly environmental practices should be increased. Addressing the exposures to environmental and occupational hazards increases the risk of disease, therefore nations need to know what can be done to prevent or mitigate the impact of disease (CDC, 2016).

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The eight Millennium Development Goals (MDGs) adopted by the United Nations in 2001 and adapted by many countries of the world including Nigeria is “to warrant environmental sustainability” with the specific set targets (The new public health, 2008). The set targets in this context are targets 9, 10 and 11 as indicated and discussed below; Target 9 focuses on the integration of the “principles of sustainable development into country policies and programs; reverse loss of environmental resources” with the aim of strengthening nations with the right policies to combat health challenges caused by environmental and occupational hazards (The new public health, 2008).

Similarly, according to UNDP (2008), target 10 focuses on the 50% reduction of the “proportion of people without sustainable access to safe drinking water in all communities”, while target 11 deals with “the achievement of improvement in lives of at least 100 million slum dwellers by 2020” (The new public health, 2008). The MDGs call for international cooperation to prevent environmental degradation resulting in global warming has led to several commitments made by developed countries and some developing countries making up to 195 agreeing to adopt the Paris agreement to fight climate change at the Paris climate conference (COP21) in December 2015 (EU Climate Action, 2018). Therefore, in line with the target 10 stated above, this project will focus on the Cholera outbreak in Nigeria as earlier discussed in my unit 3 project for this module, since it also meets the required environmental health issue for this unit’s project.

It is no news, that many poor and marginalized populations across the globe are more likely to be exposed to contaminated water, air pollution, unsafe working circumstances, and other environmental and occupational hazards (UOR, 2018). It is also no news, that Africa still remains the largest black continent and shares from poor health care situation and is greatly affected by many health issues including Nigeria with an estimated population of 182 million people (NPC, 2017). Similarly, according to Collins I. (2018), “it is important to note that genetics can mediate the effect of environmental hazards and that genetic vulnerability is not the same across populations” (UOR, 2018).
Generally, economic interest is a key driver of environmental health issues that accumulates the cost of hazard to persons indirectly involved in producing them, otherwise referred to as victims (UOR, 2018). According to the World Health Organization (2018),”Africa confronts the world’s most dramatic public health crisis and the region can address the health challenges it faces, given sufficient international support” (WHO, 2018). Africa is known to be affected by many of the factors that promote poor environmental health and this results in many health issues including Cholera which is being discussed in this module (UOR, 2018). Studies have also shown that Sub-Saharan Africa still bears the brunt of global cholera disease outbreak in this 21st century and the region experiences outbreaks that can spread across countries with a high percentage of deaths reported from cholera (CDC, 2014). The lack of basic health care services exist especially in remote areas of Nigeria, thus like many African countries, there is the dual challenge of improving water and sanitation systems as well as basic health care and prevention as package in-country (CDC, 2014).

As defined by World Health Organization (2018), “Cholera is an acute enteric infection caused by the ingestion of bacterium Vibrio cholerae present in faecally contaminated water or food” (WHO, 2018). This disease is principally associated with inaccessible safe and clean water, and lack of good sanitation in communities, particularly where there are infrastructural gaps which may include poor solid waste disposal management systems (WHO, 2018). The effect of Cholera disease is experienced more in areas that lack basic infrastructures are disrupted, inadequate or have been destroyed due to terrorism, communal crisis, war or natural disasters (WHO, 2018).
According to Ajoke Olutola Adagbada et al (2012), “A number of demographic and socioeconomic factors including age, gender, nutritional status, social status, economic status and travel abroad are also known to play crucial role in susceptibility to chlorogenic V. cholera” which poses the so what question for a developing country like Nigeria (PAMJ, 2012).

Similarly, Nigeria has continued to face complex emergencies over the last 7 years including communal crisis, herdsmen attacks, terrorist attacks on civilians and armed forces, inadequate infrastructure and related challenges, which all increases the number of potentially vulnerable communities to cholera outbreaks (WHO, 2018). Similarly, the now existence of Internally Displaced Persons (IDPs) or refugees in overcrowded settings seeking safety in places or camps lacking shelter, safe water and sanitation is quite challenging for all levels of government, thereby resulting to the use of make-shift infrastructures that increases the risk for Cholera outbreak. According to Ajoke Olutola Adagbada et al (2012), “For a cholera outbreak to occur, two conditions have to be met: there must be significant breaches in the water, sanitation, and hygiene infrastructure used by groups of people, permitting large-scale exposure to food or water contaminated with Vibrio cholera organisms; and cholera must be present in the population” (PAMJ, 2012).
Cholera which is principally transmitted through ingestion of contaminated water or food is common amongst underserved, displaced and moving populations in Nigeria resettled in camps located within schools, uncompleted building structures, town halls and makeshift settlements which will ordinarily lack good sanitation systems, access to safe and clean water and high presence of communal feeding (PAMJ, 2012). A compounding factor that increases the reoccurrence of cholera in these populations and other similar settlements, especially in regions with high rainfall, include lack of policy or non-implementation of environmental health-friendly practices, emergency response strategy and timeliness leading to the absence of environmental and occupational health medical surveillance systems (The new Public Health, 2008). Data for Nigeria shows that there was a cholera outbreak in Ibadan (Southwest-Nigeria) in 1996 and it was largely attributed to contaminated potable water sources PAMJ, 2012. Similarly, in 1995 and 1996, there was another Cholera outbreak in Kano state (Northwest-Nigeria) resulting majorly from bad water sold by street vendors and the poor hand washing habits with soap before eating food PAMJ, 2012
 
In addressing this outbreak which has been confirmed in developing countries including various parts of Nigeria since the 70’s, an outbreak detection approach that follows the epidemiological approach of finding the root cause of the disease by asking questions aided by the 5 Y’s, testing of the hypothesis prior to the environmental studies including food and water quality investigation through testing of samples (The New Public Health, 2008). The epidemiological study to test the agreed hypothesis in the determination of the causative agent or factor for the outbreak will require relevant data collected at that point in time within the affected population (UOR, 2018). At least, the popularly used 10-step epidemiological model of the European Centre for Disease Prevention and Control should be applied to confirm the outbreak and make a diagnosis, define a case in relation to the outbreak, identify cases and obtain information, describe collected data, develop hypothesis, conduct of risk assessment including identification, analysis, evaluation and establishment of control measures, which forms part of the 5 first steps (UOR, 2018).

Additionally, the other five steps of the 10-step model to be used will include the need to test hypothesis using data initially gathered, conduct a microbiological investigation and additional studies, Implement control measures agreed on by the team, Communicate results, including outbreak report, Evaluate and update procedures and toolbox (UOR, 2018). The model will help address the immediate reason for the outbreak, the location, exposed persons, causative agent, route of transmission, gather available data, analyze data, test the hypothesis and reach conclusions to design controls for the outbreak with proper communication and documentation (UOR, 2018). Furthermore, the model will facilitate the proper approach of handling the epidemic and archiving the strategies embarked on in managing the situation for specific locations to serve as a reference for others that may experience this outbreak in the future. According to Prof. Isaac Adewole (2018), Nigeria is ready to fight and prevent any import of Ebola outbreak having successfully managed in 2014 and shared best practices with other and neighboring countries (FMOH, 2018).
Presently the strategies for prevention are re-engaged with the recent announcement of the outbreak of Ebola in the Democratic Republic of Congo to prevent any reoccurrence, with learnings from the experience, where a Liberian- American visiting Nigeria was the super spreader in 2014 (FMOH, 2018). The positive effects of having strict policies for outbreak prevention and control may lead to delay in certain processes for example with the outbreak of Ebola in DR Congo in May 2018, the Federal executive council has ordered the Minister of health to intensify screening at all borders, which will facilitate prevention of the disease from entering the country and help contain any suspected case (FMOH, 2018). This could, however, lead to a few delays at the entering points and overwhelm the routine process, thus it requires proper management and more dedication of the staff on duty. Similarly, with the National Council of Health (NCH) in Nigeria reassuring commitment to fight outbreaks including Cholera reported and recently managed in Borno state, Nigeria, a state which has been under Boko Haram siege for over 5 years, the key stakeholders such as the Federal Ministry of works, Federal ministry of environment and planning and the state government need to address infrastructural gaps and have a solid response operational plan that is implementable and non-bureaucratic to avoid damage control practices (FMOH, 2018).

Conclusion:
There is a need to ensure that an ‘after outbreak action review’ should be conducted to determine and document whatever lessons were or can be learned from the experience that might be applicable to future outbreaks (UOR, 2018). Also, this review should inform the need to revise existing procedures and tools used for managing outbreaks as appropriate and shared with the broader public health community to support similar outbreak management, as we live in a global community or village. Also, in line with CDC recommendation (2014), countries need to endeavor to improve access to water, sanitation, and hygiene (WASH) program as a critical step to reducing Africa’s cholera burden and integrate same as a best practice in the traditional health system (CDC, 2014).

According to H. Tulchinsky and T. Varavikova (2008), “nutrition has a direct effect on growth, development, reproduction, and both physical and mental well-being of any individual irrespective of location” (The New Public Health, 2008). It is one of the most important factors for the health, and consequently, an essential issue in modern public health practice, hence it should be an integrated package even for persons that are displaced and using makeshift settings with pre-planned emergency response arrangements (The New Public Health, 2008). Available literature on cholera prevention and management indicates that good sanitation and nutrition are predominantly important factors for the elimination of cholera, and it is clearer by the day, that good sanitation and hygienic practices largely prevent the disease in general, hence should be promoted. (PAMJ, 2012).

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