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Swanepoel GH

Lecturer: ( epidemiology) Environmental Health

Manager: AIDS information, Training & Consultancy Centre

Technikon Pretoria, Building 4:240, P/Bag X 680, Pretoria, 0001

Tel: +27 12 3185282

Fax: +27 12 3185262







      HIV/AIDS is the most serious devastating disease that face the world today. Available information is        

      Showing that developing countries are most affected. The joint United Nations Programme on   HIV/AIDS (UNAIDS) estimates that 95% of people currently infected with HIV/AIDS AND 95% of   The lives claimed by AIDS since the beginning of the epidemic live in developing countries.

      South Africa has become the site of one of the fastest growing HIV epidemics in the world. On    average, 1600 citizens are infected with HIV each day, in addition to 4.2million South Africans who   were estimated to be living with HIV by the end of 1999. 

      National HIV prevalence rates were calculated for the first time in 1990 via annual surveys of public  Sector antenatal clinic attendees. In that year, 0.7% of the population was estimated to be HIV-positive;

      By 1999 the prevalence rate had passed the 22% mark.


      Nationally the HIV prevalence trends in South Africa developed as follows since 1990:   


       N/B: (there is a graph in this space)


      Recent estimates suggest that of all people living with HIV in the world. 6 out of every 10 men, 8 out of

      every 10 women, 9 out of every 10 children are in Sub-Saharan  Africa.


In South Africa, HIV is transmitted mostly in four ways:


v      Through unprotected sexual intercourse

v      From an infected mother to her child during pregnancy, birth, or breast feeding

v      Through contaminated blood products

v      Through contaminated needles shared by drug users




     Poverty creates the condition and environment which contribute to the spread of HIV. Co-factors

     related to poverty are:


v      Poor access to health services

v      Alcoholism

v      Sex work

v      Overcrowding

v      Poor recreation options

v      Poor access to education

v      Low literacy level

v      Unrest

v      Violence

v      Fatalism

v      Migrant workers

v      Gender exploitation and in equality

v      Cultural and traditional disintegration



AIDS on the other hand give rise to:


v      Loss of income

v      Poor access of health care

v      Alienation

v      Job loss rejection stigma and discrimination


Government’s strategic plan (2000-2005) issued in February 2000 0n HIV/AIDS/STD’s states priorities and goals in the following areas:


v      Prevention

v      Treatment, care and support

v      Research, monitoring and surveillance

v      Human rights


The primary goals are to:


    -reduce the number of new infections ( especially among youth)

    -reduce the impact of HIV/AIDS on individuals, families and communities.


The strategies being stressed are:


     -an effective culturaly appropriate information, education and communications strategy

     -increase STD management and promote increased condom use to reduce STD and HIV transmission,


      -improve the care and treatment of HIV positive persons and persons living with AIDS to promote a

       better quality of life and limit the need for hospital care.


According to this plan, it is envisaged that all government departments, organisations and stakeholders will use this plan as the basis to develop their own strategic operational plans so that all initiatives as a country can be harmonised to maximise efficiency and effectiveness.


Evaluating the already said, give rise to elaborate on the existing Primary Health Care Vision for health care delivery in South Farce by focusing on the role of the Environmental Health Officer therein.





Policy framework for a primary health care delivery system for South Africa  


According to the Official Policy document (1996) issued by the Department of Health on Restructuring the National Health System for Universal Primary Health Care (PHC), one of the critical elements of the policy framework is a significant expansion of PHC services over the next 5-10 years. It was recognised that within a context of constrained resources, expansion of the PHC system has the potential to impact on the health of all South Africans.


The basic principles forming the basis of the PHC delivery system are:


 -Universal access

 -Strengthening and build on existing public sector PHC systems

 -Strengthening the emerging district based health care system

 -A comprehensive primary health care approach that is population based regarding planning and delivery       


 -Fully integrated and consistent with other levels of the National Health System

 -Optimising the public-private mix in health care provision, and

 -Emphasising the needs and rights of users of the system, the empowerment of the users and their 

   communities to participate in governance of the health care system.

 -Services will be outcome driven, placing substantial emphasis on quality of patient care, health outcomes

  and caring aspects of health care services.

 -Decentralising management which will aim to create the maximum possible management autonomy at

   health facility level within the framework of national public service guidelines.



The PHC package ( official policy document and the White Paper on the transformation of the Health System of SA)


The public funded PHC system will, over time, provide a comprehensive package of PHC services to the entire population of the country. This package will include district hospitals services, environmental health services and other preventative, promotive and monitoring services, and comprehensive personal ambulatory services, including access to essential medicines for PHC. The list of services and related

Personnel is listed in the White Paper and Official Policy document should be regarded as indicative, and not as definite or exclusive. Decision on the inclusion of specific services and personnel will be taken at provincial and local level.


PHC Services


Personal PHC Services


· Personal promotive and preventive services, including nutrition/dietetic services, family planning,     

   immunisation and screening for common diseases, HIV/AIDS education and pre-and post test


· Personal curative services for acute minor ailments, trauma, endemic diseases other communicable

   diseases and some chronic diseases.

· Maternal and child health service such as antenatal care, deliveries, post natal and neonatal care, and care

   of children up to 18 years of age.

· Provision of essential medicine

· PHC level investigative services, including treatment of pain and sepsis

· Basic oral health services, including treatment of pain and sepsis

· Basic rehabilitation and physical therapy services, including services for people with disabilities.

· Basic optometry services

· Mental health services



· Community nursing and home care services, including care of terminally ill and geriatric patients

   ( with CBO’s and NGO’s)

· District hospital services


Non-personal PHC Services


· Health education and promotion activities aimed at groups and communities

· Health related nutrition support (with DOE. Agriculture, Land Affairs and relevant NGO’s)

· Control of communicable, non-communicable and endemic diseases

· School and institutional health services, including basic health services, audiology and vision screening, immunisation and screening and referral for disabilities.

·Health related water and sanitation services and other environmental health services

 (with the Departments of Environmental Affairs and of Water Affairs and forestry)

· Community mental health services, and substance abuse support services (with Department of Welfare, and relevant NGO’s)

· Occupational Health and Safety Services (with Departments of Mineral and Energy Affairs and Department of labor)

· Essential accident and emergency services

·  Health support services, including epidemiological services, health informatics and monitoring, and health planning and administrative capacity

· Basic medico-legal services


PHC Team


The basic PHC team should consist of the following personnel:


v      Medical practitioner

v      PHC Nurse( equipped with clinical diagnostic and therapeutic skills, including prescribing and dispensing of essential drugs included in the essential drugs programme)

v      Environmental Health Officer

v      Community Health Nurse

v      Health promotion/education specialist

v      Social worker

v      Community Health Workers

v      Rehabilitation personnel (physiotherapist/occupational therapist assistants or other community based rehabilitation personnel, occupational therapist, physiotherapist and speech and hearing therapist)

v      Oral hygienist/Dental therapist

v      Pharmacist/Pharmacy assistant/Technician

v      Nutritionist/dietician

v      Optometrist

v      Dentist

v      Radiographer

v      Lboratory technologist/technician

v      Pathologist/Microbiologist


The White Paper on the transformation of Health Services go one step further and indicate amongst others the training need of categories of health workers, which are:


v      PHC nurses and advanced midwives

v      Environmental Health Officers and Assistants

v      Community psychiatric nurses and psychologists

v      Paediatric nurse

v      Nutritionist

v      Epidemiologists

v      District health managers

v      Psychologists

v      Occupational therapists and physiotherapists


One further implementation strategy which are mentioned in the White Paper is the PHC-orientated curricula


Health sciences curricula should be restructured to reflect community needs more accurately, and teaching should place greater emphasis on community and outcome based programmes


The fundamentals of community needs-based health sciences curriculum are:

·         PHC,

·         Social science,

·         Health promotion,

·         Ethics,

·         Basic management,

·         Community participation,

·         Conflict resolution and communication,

·         Basic counselling,

·         Epidemiology,

·         Research methodology and information use, and

·         First aid (emergency care)


Provision should also be made for the development of educational programmes on the rational use of essential generic drugs.


Nutritional support, monitoring and rehabilitation should be incorporated with the training of all PHC providers.


Lastly it is stated that all levels should receive training in the analysis and use of data collected in terms of the National Health information System of South Africa.


Said that, the following part will concentrate on the ideal training, characteristics and positioning of Environmental Health Officers as AIDS Health Worker.




 Environmental health is defined as: “ A condition of optimal, physical and wholesomeness of all mans living environments and it comprises those factors ( biological, chemical and physical) in the micro and macro external environments that can have a negative (positive) influence on human health.


An Environmental health service ( within the primary health care approach) is “The absolute front line non-personal primary health care service mainly rendered by Environmental Health Officers aimed at the limitation ( to a realistic and practically attainable degree) of health risks to which man is subjected in his physical environments ( residential-,work-, recreational-, educational-, in-transit-and rehabilitation environments with regard to the components of the atmosphere, water, food, shelter, sanitation/general hygiene, energy and other)”


The mentioned professionals are trained at Technikons all over South Africa within six fields, i.e.


¨ Community Development

¨       Epidemiology

¨       Environmental planning and pollution

¨       Food and meat hygiene

¨       Occupational Health and Safety

¨       Management Practice


The report on a workshop held at Buffelspoort in January 2000 on Transformation of Environmental Health Human Resource Development states that:


§ The majority of the current Environmental Health Practitioners in South Africa have been trained/developed to apply or enforce legislation and standards.

§ The development of human resource were mainly to produce a technically competent practitioner in identifying, advising and applying required legislation.

§ The human resource tended to be deployed more in urban than in rural areas.


It is also states that with the birth of PHC in 1978 and the democratisation of South Africa in 1994 institutions of learning should have adopt the principles of PHC in the training.


It was actually done as mentioned in the document on all aspects, i.e:


ª Equitable service

ª Team work

ª Community participation/involvement

ª       Participatory approach and

ª       Emphasis on the joint planning and implementation


The following have also been stated in the same document as expectations from the National Department for Environmental Health Practitioners of the twenty first century in South Africa:


ª Proper training in principles and technicalities of Environmental Health: that means ‘be able to identify,    

    evaluate, control and prevent all factors ( biological, chemical and physical) in man’s environment which

    exercise a deleterious effect on his/her physical, mental and social well-being and development’


ª Be properly orientated about the socio-political and economic issues of the country


ª Be able to organise and manage his programme and project in order to ensure desired outcomes; and that

    all can be possible



q       In collaboration with other Government Organisations

q       In collaboration with other sectors with interest and expertise in the field

q       With the participation and involvement of communties concerned in planning, implementing and monitoring of projects and programmes. This involvement of communities in addressing their own problems has a sustainability, capacity building and a socio-economic uplifting element

q       With the use of relevant data and information for  better decision making

q       Working with other team members

q       With the use of relevant technologies to the benefit of communities and for sustainability; and

q       Interpreting and applying international and national activities for the benefit of communities and the environment.

Taking the above in consideration it is with great pride to state that most of the mentioned aspects is already in place by Technikon Pretoria and that students been exposed to many of these aspects in theory and practice.


Said that, the following diagram is clearly showing the pillars of the make-up of Environmental Health Officers in South Africa.







                                      community               law enforcement

                                      developer                  officer



The core function of the Environmental Health Practitioner are as follows



                   Health Promotion, Education and training (formal and informal)






                                   Law enforcement                Administration & management

                    Acts, Prov Legislation,        Policy, Organisation, finances,

                                    Regulations, codes &           Personnel, procedure &control



Environmental Health components applicable to the activities are:


1.        Accommodation

2.        Water

3.        Energy

4.        Atmosphere

5.        Biological pest and vector control

6.        Food

7.        Occupational Health and Safety

8.        Sanitation






With the given background and make up it is clear that the Environmental Health Officer is part and parcel of the PHC team, do have the perfect training as health promoter, community developer, law enforcer and is a professional by excellence.


For Primary AIDS Care, the Environmental Health Officer is essential and a key figure in the prevention programmes and impact it will have on the broader society and very specific in the small workplace.


Trained as technologist on the one hand and community developer on the other, the Environmental Health Officer are situated in an ideal position to play unique strategic role.


Main areas in HIV/AIDS which are directly applicable to environmental health are:


1.        specific biological agents and determinants applicable to AIDS related condition


Conditions may occur during the symptomatic/severe symptomatic phase and can be the result of the overgrowth of some of the body’s natural flora with fungal infection and reactivation of infections (such as TB and herpes).  They are also due to uncontrolled multiplication of HIV itself. The severe opportunistic infections progresses in cancers and HIV-related organ damage.

The following table list the common opportunistic infections and cancers associated with AIDS.




Condition and target organ/s





-Mycobacterium tuberculosis-lungs and other organs including the meninges, brain, kidney and bone marrow

-Group B streptococcus-lungs (usually in children)

-Heamophilus influenza-lungs (usually in children)

-Pneumococci-lungs and blood stream

-Salmonella-GIT and blood

-Atypical mycobacterium-lungs and other organs



-Herpes simplex-skin, brain, oesophageal, oral and nervous system

-Herpes zoster (shingles)-skin, eye, brain and nervous system

-Cytomegalovirus-lungs, retina, brain, GIT, liver, kidneys & bone marrow



-Pneumocystis carinii-lungs

-Toxoplasmosis- meninges, brain and eye

-Cryptosporidium-GIT and gall bladder



-Candida-mouth, oesophagus, GIT, vagina, skin and nails

-Cryptococcus-meninges, brain, lungs & bone marrow

-Histoplasmosis-lungs & bone marow


-Karposi’s Sarcoma-skin, GIT



2.        Socio-economic and environmental conditions which should be addressed are:


·         Poor access to health care

·         Overcrowding

·         Poor recreation options

·         Poor access to education

·         Environmental sanitation(sewerage, water and waste)

·         Cultural


3.        Legal aspects applicable to HIV/AIDS and public health


v      Application of health legislation especially for the small workplace where some of the related conditions of HIV/AIDS may impact on the workplace with other legislation protecting the worker.(e.g persistent diarrhoea)

4.       Most important, the Environmental Health Officer as the only health professional as part of the PHC Team visiting the small business.


Workplace programmes are clearly guided by guidelines from the Department of Health with aspects applicable and addressing the needs of the small business. In this respect a niche has been found where the Professional Environmental Health Officer can actively contribute by:


§         Doing specific health promotion on STD’s/HIV/AIDS and other related conditions in the small workplace

§         Training, facilitate and support the owner of the small business on the implementation of a small workplace programme including all legal requirements and other impacts


 Aspects to cover in such a small workplace programme are :


§         Policy development and legal issues

§         Education

§         Prevention & unirvesal precautions

§         Personnel issues

§         Wellness management

§         Reference and resources


To enable the Environmental Health Officer to be able to implement and sustain such a programme in his/her district, they should be trained and serve on local and regional forums regarding HIV/AIDS.


Including HIV/AIDS in formal training programmes as health/developmental issue




Content &application by student







Value clarification, introduction to basic facts. Including issues in formal programmes, i.e.

Community Development 1, and Environmental 

Planning 1as assignment ( creates openness, give facts, refer, awareness, needs assessment at fellow students or community projects, surveillances)







More emphasis on care and support and outreach. Specific training in all second year subjects to equip the student to act as peer helpers at technikon and in community. ( Health promotion, exhibitions, educators, counsillors at AIDS centre’s, informal research)







Emphasis on planning, programme (workplace) development and epidemiological surveys ( Health promotion, educators, counsillors, surveys, mentorship, programme development, industrial support)



    Workshops for practicing Environmental Health Officers in the field already in place







3 days




Basics such as value clarification, statistics, basic facts and epidemiology, STI’S &STD’s, sex and sexuality, legal aspects, HIV testing, living with AIDS, unirvesal precautions, co-factors etc.


5 days


Health promotion

Befrienders(3 days) plus methodologies to get the message across, new dynamics of learning, community based programmes etc.



5 days



Programme Development

Befrienders (3 days) plus principles for programme development and implementation. Helping skills to management and co-ordination of projects/programmes 

10 days


Befrienders plus needs for counselling, counselling models counselling skills, pre-and post counselling, trauma, specific needs of PWA’s, individual and family counselling etc.



HIV/AIDS is not only a health issue but more a developmental issue that will impact on all sectors of society. It is important that all levels of government take note of this specific niche and that such a programme receives the necessary support and recognition needed to be carried out and to sustain it not only to improve the quality of life of people but to address those factors Environmental Health Officers are responsible for tha have an effect or impact on health.


A health promotion package(including an educational flip chart) and training manual is already in the process of final development and an implemental guide for the small business owner is available as part of the package.


























Guidelines for developing a workplace policy and programme on HIV/AIDS and STD’s.

Department of Health: Directorate: HIV/AIDS and STD’s


Evian C. 2000. Primary AIDS Care. A practical guide for primary health care personnel in the clinical and supportive care of people with HIV/AIDS. Third Edition. Jacanana Publishers.


Transformation of Environmental  Health Human Resource Development. Workshop: 19-20 January 2000. Buffelspoort.


Restructuring the National Health System for Universal Primary Health Care. Official Policy document issued by the Department of Health. January 1996.


White Paper for the transformation of the Health System in South Africa. Government Gazette, No 17910, vol 382. 1997


District Health information system Guidelines. Department of Health. February 1998.


Interview . M Fourie. ATICC Pretoria. 











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