Public Health is Environmental Health By Prasanna Cooray It was said in the pages of this newspaper (precisely on 18.09.2008.

), in the wake of a spreading epidemic of Leptospirosis, under the caption Leptospirosis: Get the full story, that public health is nothing but environmental health. It was only last month, the Health Minister Maithripala Sirisena said in parliament that the only effective mechanism to curb the dengue epidemic is maintaining a clean environment. I hope that now we can assume that the Minister of Health has chosen the right path for dengue control. It is heartening to note that the Minister of Health has been advised correctly on this matter by his advisers; and even more that the advisers themselves have come to acknowledge the interlacing nexus between public health and environmental health. It was over seven years back The Island took dengue head-on, and published a series of articles on possible remedies for a day by day worsening dengue epidemic in the country at then. Those pages were tabled in parliament at a special session on the dengue epidemic by then MP for Gampaha district S. Amerasinghe on 22 July 2004. Among others, we said loud and clear that dengue is nothing but a health manifestation of a worsening environmental debacle. Now, as Minister of Health too has come to endorse that view there is reason to rejoice. For, that is good both for the public health and environment of the country. Hurrah, we say on behalf of the public health and the environment - the two sides of the same coin. If ministers words were to be transformed to deeds, then we are on course for a good time. Clean Environment with a pinch of salt However, the notion of clean environment is not without its share of reservations. In fact, in a way, we are lucky that now we have many lessons in store, pre-tested and ready for replication, accruing from the past experiences of the West. Many decades back, the West trailed along a path for freedom from environmental health problems through creating a clean environment. They believed that improving the economy and achieving economic prosperity (the growth model) will also lead to a clean environment and elimination of environmental health problems. However, by today, this model has turned out to be one with mixed-results. True that one can argue that the West did not experience epidemics of the magnitude of the black death (in the 1300s-1400s and again in 1700s, with a guesstimate of 34 million deaths amounting to one third of the Europes population then), Russian flu (1889-90, which killed 250,000) or Spanish flu (1918-19, which caused a staggering 50 100 million deaths worldwide in the space of just six months), this side of 1950 barring the polio outbreak of the US in 1952 that killed 3,000. But on the other hand new environmental health problems in the form of the global warming and depletion of ozone layer have emerged. Scientists predict that if these issues are unaddressed and unabated early enough, the resulting consequences would be as grave as or worse-off than those experienced during the pre-environmental sanitation era of the Europe. However, the West has not been able to keep the infective agents at bay altogether. At the same time, the invisible environmental pollution too has lead to a whole heap of health issues in the likes of allergies or hyper-sensitivities and contamination of the environment by toxic chemicals. Still influenza kills around 36,000 annually in the US alone (compared to 15,000 deaths per year from AIDS in that country). Asthma, a problem largely attributed to environmental pollution is a leading cause of death and disability in the Western world. Waste incineration to keep the environment clean has lead to the release of chemicals such as dioxins and furans to the

environment, two of the most toxic compounds in the world. Bio-monitoring tests measuring chemicals in the US population conducted by the Center for Disease Control (CDC) has picked no less than 148 toxic chemicals in the clean environment. So, in short, the clean environment model, as practiced in the West, is not without shortcomings and these are the very points to ponder if we are to embark on a similar track on our way to good health. If one thinks creating a disease free clean environment through the use of chemicals then that is definitely precarious. After having used and abused chemicals for many decades, we have enough and more examples to prove this point, both from within and without Sri Lanka. Within Sri Lanka, now we have come to be plagued by the worst public health devastation of our time, Chronic Kidney Disease (CKD) affecting the people of the North Central Province, which is no more a disease of unknown aetiology. The disease is estimated to have killed 10,000 already and another 100,000 diseased, kicking their heels without hope. Researchers have shown the possible association of cadmium to the disease causation, including its presence in cadaveric renal biopsies. Cadmium in abundance is found in triple super phosphate, an agro-chemical used freely in Sri Lanka. It is now the responsibility of the authorities to take cognizance of this fact for the greater good of the citizenry of the country. In the global scene, the sorry tale of malaria and the use of chemical insecticides is a case in point. Over reliance of chemical insecticides in the control of malaria has given only less than marginal success. Even today, according to WHO estimates malaria accounts for 2.7 million deaths a year. DDT, Endosulfans, and Endrin (used as a pesticide against insects and rodents) are examples of toxic chemicals that have been either banned or severely curtailed in their use after their deleterious effects on humans and the environment were discovered. So, in short, our quest for a disease free clean environment should be one which dissociates and disengages itself from the chemical lobby forthwith. On a concluding note, it is encouraging that the Minister of Health, links the importance of clean environmental to none other than dengue control. However, with the tool available at present, the Mosquito Breeding Control Act No. 12 of 2007, whether this would be possible is another question. If one reads through this 15 page document, any tangible measure for dengue control except the authoritative tenor it reflects throughout its entirety will be hard to find. Further, the Act has placed its reliance on chemical larvicides and pesticides to supplement the environmental cleansing measures it has proposed. Hardly any attempt has been made to harness the public support for dengue control in the community. Instead, it maintains a punitive stance against the public. The authorities need to come out of this colonial mentality and should reach for the assistance of the public towards dengue control. No piece of legislation will give the desired results unless it ensues public support. (In this regard, Prof. Kalinga Tudor Silvas sociological inquiry titled Malaria Control as a legacy of Colonial Discourse: The case of Sri Lanka giving enough insights from the malaria control strategies of the colonial times, is worth considering by the authorities). In essence, whether sufficient multi-stakeholder consultations and researching have gone into the Act before its formulation remains a big question. Through the Act, a lot of power has been vested with the public health authorities to carry out measures that are believed to be prudent for dengue control. In practice, this is what led to those cleaning-sprees of the environment that even went to the extent of total elimination of greenery

from many house yards across the country. We have also experienced discriminatory fogging, the effectiveness of which in bringing down the dengue incidence has always been refuted. A little more than a year ago The Island surfaced an incidence of Toxorhynchites (the mosquito eating big mosquitoes) dying in large numbers in Anuradhapura following fumigation for dengue control, about which even an editorial titled Lets stop killing our enemys enemy was written (30.09.2010). However, the news is that the authorities are still to be satisfied with these powers, and more teeth is to be put into the existing law in order to further strengthen the hands of the public health authorities. Anyhow, the bottom line has been that dengue continues to test the integrity of the health system of the country while a sustainable remedy remains something long overdue. So, it is in this context that we need to remind the authorities that public health is nothing but environmental health.