Environmental health practitioners and the COVID-19 pandemic

This opinion piece is an attempt to address the fact that members of the public health workforce may be unaware of the range of work environmental health practitioners do and how they can contribute to improving public health and community resilience and address social determinants of health.

When pandemic infection became established in countries that failed to initiate immediate measures of control, the impact was felt in ways that had not been anticipated. With notable exceptions, many governments around the world found themselves ill-prepared for a crisis that would demand a multifaceted response. These exceptions tended to be where pandemic disease had been experienced previously, or where the administration mobilised their entire public health workforce, including those in environmental health, to perform the fundamental disease control measures. This was especially evident in parts of Africa that had experienced Ebola, or where life-threatening infectious disease is endemic. ¹ Despite environmental health practitioners (EHPs or EHOs) contributing to public health in local communities, their importance has sometimes been passed over in the UK before and during the pandemic.

Elsewhere, countries came to realise that environmental health – with its role securing the control of risks to health from food, poor housing conditions, environmental pollutants, occupational hazards (in the UK, local authorities via their EHOs are the main enforcing authority in retail, wholesale distribution, warehousing, hotel and catering premises, offices and the consumer/leisure industries), vector control and infectious agents – was pivotal in delivering health protection to their communities. The disappointment is that, in England (unlike Wales for example), EHPs, trained in infectious disease control and investigation, were not called upon soon enough to support their small standing public health workforce in ‘contact tracing’ to help contain the spread of infection.

With public health being reorganised again with the creation of the Office for Health Promotion and the UK Health Security Agency, it is appropriate to consider and highlight the work of EHPs and how their skills and expertise could be better utilised to address some of the issues highlighted by the pandemic. It has been suggested ‘Aside from the direct health and economic impacts of COVID- 19, the pandemic provides an opportunity to view medical and public health issues through a new lens’. ² The pandemic has exposed the long-standing structural drivers of health inequity, such as precarious and adverse working conditions, growing economic disparities, and this is unlikely to be the last pandemic. ³ The work of EHPs can help address health inequity as we reduce the restrictions introduced to help control infection rates.

EHPs, wherever employed, are not just about enforcement, and regulatory activity, they achieve a great deal by way of advice and education to achieve their objectives in all areas of their work. Their work relates not only to obvious public health but also can help the economy continue safely. Day reports ¹ that in the pandemic, EHPs were able to ‘engage with business and the public’, using their skills and experience. During ‘lockdown’ and restrictions, EHPs found their knowledge and skills to be at a premium as a plethora of regulatory instruments emerged from central government to do with restricting, and subsequently prohibiting, activities where the virus might be transmitted. This became particularly important as close-contact operations sought to re-open, with EHPs using their technical understanding and inter-personal skills to excellent effect.

The economy cannot function fully if there is not good public health and adequate community controls of COVID-19. Could EHPs not have been entrusted to issue ‘consent to operate’ certification once safe systems of work including adequate ventilation were in place? Such a system exists in New South Wales with ‘Covid-19 Safety Plans’ ⁴ that are checked by authorised persons. ⁴ This might have been a better approach than blanket closures, certainly so far as public mental health is concerned. Their work adequately resourced can also improve resilience.

Taking housing as another example of one area of environmental health work, the pandemic has shown how self-isolation in poor quality, possible multi-occupied or crowded housing, is difficult and problematic for control of infectious disease. Within-household transmission is said to be responsible for a significant number of infections.^5,6 EHPs have advised landlords and tenants on how to reduce risks and meet regulatory requirements in the pandemic. Yet, addressing crowded housing or lack of space is difficult when there is a lack of alternative accommodation. Furthermore, many households were living with long-standing repair and quality issues, some of which got worse or more obvious during lockdown, and run-down homes result in run-down people. ⁷ While the COVID-19 pandemic has served to highlight the role housing plays in health, it is a critical wider determinant of health at all times ⁸ (and is crucial to ‘building back better’). ⁹ This is a key area of work for EHOs and significant hazards in housing have been estimated to cost the National Health Service (NHS) in England £2.0bn per year. ¹⁰

It does seem the wrong time to reorganise the public health infrastructure and will be flawed if the full role of EHOs (EHPs) is not taken into account. As one distinguished public health commentator has said, ¹¹ ‘although vaccines will undoubtedly help control the pandemic, a continuing and strengthened community based public health response to COVID-19 at a local level is needed’.

It would make sense for there to be a Chief Environmental Health Officer within at least one of the new agencies. The Office for Health Improvement and Disparities (OHID) will sit within the Department of Health and Social Care (DHSC), to lead work across government to promote good health and prevent illness ‘building on the work of Public Health England’. ¹² The areas of work of EHPs are the responsibility of different government departments. Taking housing again as an example, this is the responsibility of the Department for Levelling Up Housing and Communities. If the OHP aims to prevent illness that ‘costs the NHS billions every year’ given what has been reported, ¹⁰ should there not be a Chief EHO in the OHP and indeed the UK HSA?