Environmental health in Egypt

Int. J. Hyg. Environ. Health 206, 339 ± 350 (2003) ¹ Urban & Fischer Verlag http: // www.urbanfischer.de/journals/intjhyg

International Journal of Hygiene and Environmental Health

Environmental health in Egypt Wagida A. Anwar Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt Received July 23, 2002 ¥ Revision received November 7, 2002 ¥ Accepted November 18, 2002

Abstract Egypt shares most of the environmental problems of developing countries. One of the most important health and environmental problems is air pollution resulting from using fuel, burning operations, and the increase of automobile exhaust in cities. Moreover, the deficiency of efficient sanitation services and water pollution caused by the breaking down of old and consumed water networks, as well as the various problems in construction, designing and maintenance of sewage system resulted in the appearance and prevalence of communicable and non-communicable diseases. There are several examples of exposure to chemical genotoxicants, and lifestyle exposures in the population, which create unique combinations of environmental risk factors for diseases such as cancer. Environmental factors may interact with infection and lead to enhancement of carcinogenicity processes. Currently, there is a growing interest in environmental mutagenicity and carcinogenicity research. The use of different biomarkers and genetic susceptibility testing can contribute effectively to risk assessment. The Government of Egypt recognizes and deals seriously with these problems. The State Ministry of Environment has initiated new policies that include risk minimization, law enforcement, treatment of pollution at source, mitigation procedures and inter-sectorial collaboration. The Ministry of Health and Population recognized the link between economic development, environment and health. It elaborated a national environment health strategy in accordance with the format of the regional and global environmental health policy. This strategy identified priority areas, which requires further action to be taken and to be implemented. Environmental health was included as one of the four main objectives of the strategic Healthy Egyptians 2010 Initiative. Specific objectives and plans for the initiative are presented. Key words: Environment ± pollution ± health ± biomarkers ± genetic susceptibility ± Egypt

Introduction The economic benefits from modernization, industrialization and technology transfer have always been attractive to decision makers. However, very little attention has been paid to the potential

negative impact of their related activities. They generate problems such as air pollution, discharges of new solid and liquid wastes to surface, coastal and ground water resources, and waste products carrying toxic chemicals and metals. These problems can have long-lasting adverse effects on land, water as

Corresponding author: Wagida A. Anwar, MD, Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Abassya, Cairo, Egypt. Phone: ‡ ‡ 202 683 7862, Fax: ‡ ‡ 202 483 7888. E-mail: [email protected]

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well as food and ultimately on all forms of life. It is obvious that the success of modernization and industrialization needs to be carefully evaluated on the bases of economic benefits and associated risks. A major area of concern is environmental health. Environmental health comprises those aspects of human health, disease, and injury that are determined or influenced by factors in the environment. This includes the direct pathological effects of various chemical, physical, and biological agents, as well as the effects on the broad social environment, which includes housing, urban development, land-use, transportation, industry, and agriculture (WHO, 1997a). Poor environmental quality is estimated to be directly responsible for approximately 25 percent of all preventable ill health in the world (WHO, 1997b). A major challenge in Egypt is balancing the rapid development process and economic growth with minimizing the serious impact on environmental health.

Overview of environmental health problems in Egypt Air pollution Air pollution continues to be a widespread public and environmental health problem. It causes premature death, cancer, and long-term damage to respiratory and cardiovascular systems. Industrial activities are one of the major sources of air pollution in Egypt. Eighty-three percent of the industries are located in Greater Cairo and Alexandria. In Helwan, an industrial suburb of Cairo, 29% of school children suffer from lung diseases compared to 9% in rural areas of Egypt. (Healthy Egyptians 2010 Initiative, 2000). Another important source of air pollution in greater Cairo is motor vehicles. Fortyfive percent of the motor vehicles in Egypt is found in Cairo and 13% are in Alexandria. An annual mean lead concentration of 4 mg/m3 in ambient air at about 9 m above the ground surface was found in Cairo city center during 1994. Much higher concentrations, of more than 12 mg/m3, were recorded in the busy streets of Cairo (Nasralla, 1997). This resulted in high levels of lead in blood of Cairo residents and much higher concentrations in traffic policemen reaching more than 60 mg/100 ml blood which was recorded during the 1980's (Nasralla et al., 1984). As a result of the use of unleaded gasoline, monitoring activities showed a great reduction of lead concentration in the air in Cairo reaching less than the air quality standards of 1 mg/m3 (Hendy et al., 2001).

Water pollution Water pollution is one of the principal environmental and public health problems Egypt and the Middle East region are facing. Contamination of water can result from both industrial and agricultural sources. Deficiencies in the treatment of wastewater, the disposal of untreated sewage, and inadequate operation and maintenance of treatment plants result in health risks. Biological and chemical contamination significantly reduces the value of surface water for fishing, swimming, and other recreational activities. As agricultural activities are the principal source of economy in Egypt, high concentrations of pesticides are found in the Nile and in Rosetta and Damietta branches. Drainage and wastewater from agricultural run-off, industrial effluents and domestic sewage are discharged through drains into delta lakes. These lakes are of high economic value as a natural resource for fishery, recreation and for migratory birds. Lake Manzala is considered one of the most important lakes in Egypt. However, the lake receives heavy loads of organic and inorganic pollutants via several agricultural drains from six governorates (Dakahleya, Sharkia, Qualiobia, PortSaid, Damietta, and Cairo). The main drains contributing to the pollution of Lake Manzala are Bahr El Baqar, Hadous, Al Serw and Faraskaur (Badawy et al. 1995). This led to increased concentrations of heavy metals, microorganisms and parasites in the lakes' water, edible plants and fish. It was reported that the levels of heavy metals in the lake water and in the sediments were higher than the tolerance levels or limits of the Egyptian General Authority for Standards and Quality Control. Lindane, HCB, DDT and their metabolites were detected in all fish samples. It was also demonstrated that fish samples were contaminated with low concentrations of chlorinated hydrocarbons (Badawy and Wahab, 1997). Although many studies and monitoring efforts have been carried out, information on water quality status, its causes and effects show many gaps. This calls for an adequate routine system, a data base and information system and an integrated modeling approach, to analyze the impact of individual pollution sources on ambient water quality, to predict future problems, and to evaluate the efficiency of proposed actions. Further degradation as a result of development, population growth, industrialization and the need for new agricultural areas and water use will increase the requirements for appropriate actions to prevent further pollution. Better environmental services such as sewer service,

Environmental health in Egypt Table 1. Trends in regional cigarette consumption 1990 ± 1997. (Percent change by volume) Latin America and Caribbean North America Western Europe Eastern Europe Africa Asia and the Pacific Middle East

16.5% 7.6% 5.9% 5.0% ‡ 3.6% ‡ 8.6% ‡ 24.3%

wastewater treatment service, and safe drinking water may help to balance between social and economic factors and protect the environment in border communities and natural areas. Exposure to hazardous substances The effects of the tobacco epidemic will increase substantially in the Middle East due to a marked increase in tobacco consumption. Tobacco consumption in the Middle East Region increased by 24.3%, from 1990 ± 1997. This is by far the largest increase in any region in the world (see Table 1). If this trend is not reversed the health and economic impacts will become a very substantial burden on the countries in the region (Tobacco Control in Egypt, 2001). The Middle East produced 13.1 percent of all cigarettes in the world and 3.7 percent of all cigarette sales occurred in this region. Overall, cigarette imports decreased by 6 percent in the region from 1992 to 1997 and cigarette exports increased by 115 percent (CDC, 2000). Recent data showed that 13 million Egyptians are smoking 85 billion cigarettes annually as compared to 9 million smokers in 1980. About two-thirds of the tobacco consumed in Egypt is in the form of manufactured cigarettes, while the remaining onethird is consumed as water-pipe tobacco (Shisha). The latter is made up of a blend of tobacco, molasses and in some cases flavorings such as apple, mint and citrus flavors (Healthy Egyptians 2010 Initiative, 2000). At present, statistics prove that about 500 000 are under 15 years of age (3.8%) and 73 000 under 10 (0.57%). The average increase of new smokers is approximately 25 persons every hour. In 1997 it was found that 11% of adolescent boys are smokers but girls do not smoke this much. Some studies indicated that 35% of males and 16% of females of university students are smokers. There has been a marked increase in the number of young Egyptian women who smoke tobacco from water pipes (Shisha) in upscale cafes and restaurants (Tobacco Control in

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Egypt, 2001). A study conducted in 1998 about smoking prevalence among adolescents indicated that 15.4% are smokers among working adolescent boys who are not in school compared to 7.6% among non-working adolescent boys. Among professional groups, smoking prevalence is highest in teachers (45%) and doctors (43%). By estimating the economic burden of smoking on the Egyptian families, it was found that about 5% of the family income is spent on smoking, a very high percentage when compared with 4% expenditure on health care, 2% on education and 2% on culture, sports and entertainment (Tobacco Control in Egypt, 2001). For the majority of environmental hazardous substances, critical information on the level of exposure and the association with health effects is lacking. As a result, efficient health-outcome measures of progress in eliminating health hazards in the environment are unavailable. The identification of toxic substances and waste, whether hazardous, industrial, or municipal, that pose an environmental health risk represents a significant achievement in itself. Public health strategies are aimed at tracking the nation's success in eliminating these substances or minimizing their effects. The introduction and widespread use of pesticides continue in agricultural, commercial, recreational, and home settings. As a result, these often very toxic substances pose a potential threat to people using them, especially if they are handled, mixed, or applied inappropriately or excessively. Potential exposure from the environment can be estimated by environmental monitoring. Actual exposure (uptake) is measured by biological monitoring of human tissues and body fluids. Biomarkers are used to detect the effects of pesticides before adverse clinical health occur (Anwar, 1997). The improper use of pesticides may endanger biological effects beyond those for which they were originally manufactured. Adverse effects may be caused not only by the active ingredients and the associated impurities, but also by the solvents, carriers, emulsifiers and other constituents of the formulated products (AlSaleh, 1994). Furthermore, children are at increased risk of pesticide poisoning because of their smaller size and because pesticides may be stored improperly or applied to surfaces that are more readily accessible to them (Au, 2002). The use of persistent organochlorine insecticides is being banded or restricted. However, residues of DDTs, lindane and other organochlorine insecticides were reported to persist in national water bodies and accumulate in fatty tissues of living organisms (Badawy and El-Dib, 1984; El-Dib and

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Badawy, 1985; Abou-Donia 1990). The problem asks for a sound baseline study, including a review of pesticide use, import and production, and measured concentrations. With rapid growth in urban population and industrial activities, the problem of municipal and industrial solid waste is increasing. About 6 million tons of municipal solid waste are generated annually in urban centers, and 10 million tons for the whole country. The annual amount of hazardous waste from industrial activities is estimated at about 20 000 to 50 000 tons. In Egypt, little is known about the health impact of the solid waste on the population. A national policy needs to be developed and implemented (Spengler and Falk, 2002; Au and Falk, 2002). Slum areas suffer from lack of resources and expertise to properly manage solid waste, handle and store pesticides and other hazardous materials, supply sufficient drinking water, and support other sustainable development efforts. Nations need to make choices about how to deal with such regions; offering technical assistance is an option to speed knowledge transfer and reduce environmental harm. Environmental mutagenicity and carcinogenicity Egypt has unique circumstances of public health problems making it an ideal setting for increased attention to environmental mutagenicity and carcinogenicity research. Some examples are exposure to chemical genotoxicants (e.g., automobile exhaust, pesticides, metals and cytotoxic drugs) and to lifestyle factors (e.g. consumption of tobacco products) that have been linked to the expression of biological effects and to increased risk for cancer (Anwar and Gabal, 1991; Anwar, 1991, 1993a, 1994a, 1994b; Ashby et al., 1993; Anwar et al., 1994a, 1994b; Anwar and Shamy, 1995). Infection can be associated with cancer development. Environmental factors may interact with infection and lead to enhancement of the carcinogenic process. The high prevalence of viral pathogens (e.g. high endemic rates of hepatitis C viral infection), knowledge gained from studying geneenvironment interactions would be very helpful for understanding and controlling disease risks around the world (Abdel-Aziz et al., 2000; Frank et al., 2000; Nafeh et al., 2000; Habib et al., 2001). In recent years, the incidence of cancer in Egypt has increased. A substantial number of Egyptians are suffering from primary hepatocellular carcinoma (PHC) which is mainly preceded by hepatitis B virus infection. It has been shown that aflatoxins are potent carcinogens in a number of animal species.

Aflatoxin B1 has been classified by the International Agency of Research on Cancer as a group I carcinogen. It has been suspected as causal agent in the induction of hepatocellular carcinoma (IARC, 1994). The role of aflatoxins in carcinogenesis is complicated by Hepatitis B virus infection (Wild et al., 1992; Anwar, 1993b; Anwar and Wild, 1994). Schistosoma heamatobium infection is one of the most common health problem in Egypt. It is strongly associated with the development of urinary bladder carcinoma (Rosin and Anwar, 1992; Rosin et al., 1994a; Rosin et al., 1994b; Hirvonen et al., 1996). Lung cancer, which is mostly related to air pollution and smoking, is more common in urban cities than rural villages. In urban areas, exposure to low levels and short-term peak levels of engine exhausts are ubiquitous. Higher exposures to engine exhausts may occur in some occupations such as that of traffic policemen. Consequently, they show increased chromosome damage and the damage was enhanced further by smoking (Anwar and Kamal, 1988). Agricultural workers exposed to pesticides showed increased incidence of chromosomal aberrations and sister chromatid exchanges (Anwar, 1994a). Around the world, an emphasis is on understanding genetic susceptibility to the development of environmentally related cancers. An initial focus was on the inheritance of variant chemical metabolizing genes on the development of cancers (Anwar et al., 1996; NIEHS, 1997; Au et al., 1999a, 1999b; Sierra-Torres, 2002). Another focus is on children's susceptibility to environmental health problems. Egypt needs to develop international collaborative projects in these two priority areas to address our environmental health concern.

Prevention and control Since environmental health problems have increasingly become a global issue, attention should be given to environmental pollution and its effect on the health sector, taking into consideration the political reactions and interactions on the national and the international level. Egypt can contribute to improving the health of people internationally, not only as part of a shared goal for humanity, but also because a healthy population has positive social and economic benefits throughout the world. A global scope will help develop and achieve effective ways to prevent disease worldwide. The target of having healthy people all over the world will never be achieved without strengthening

Environmental health in Egypt

the integration of the local, regional, national and international processes. While planning and implementing national health policies, countries should consider seriously the importance of international regulatory decisions, the situation of its socioeconomic development, the interaction with the global political action to solve problems with global implications and the popular participation at grass roots. Many countries have resources available to protect their populations from adverse health impacts, whereas other countries should expand their efforts to improve environmental conditions to enhance the health of the people. They should also increase collaboration, coordination, and outreach efforts with the rest of the world to help close the gap between existing and attainable health status. Consultation and assistance on numerous environmental health issues will help reduce illness, disability, and death, thus leading to a healthier global community. The impact of the environment on human health is so great, that it is considered one of three primary factors that affect human health. The other two are genetic factors and personal behavior. Therefore, national and international efforts to ensure clean air and safe supplies of food and water, to manage sewage and municipal wastes, and to control or eliminate vector-borne illnesses have contributed a great deal to improvement in public health all over the world. There are several attempts to identify environmental threats and to propose solutions for their mitigation. Environmental health problems can be managed and prevented in different ways. One of them is that governments should closely cooperate with non-governmental and international organizations to help improve human health on a global scale. Our goals go beyond problem discovery and description. They should also focus on research and observation for problem solving within the context of an evaluation of the practicability and scope of solution. In view of all the above, tackling environmental pollution is realized through intersectoral cooperation and collaborative efforts involving several ministries (Ministries of Health, Environment, Labor, Interior, Industry, Public Works and Water Resources, Housing), public and private organizations, and agencies and academic institutions. This cooperation will help to properly manage the country's environmental resources and cultural and natural assets. Key priorities and needs for improving health impact assessment are examined, and an agenda for further actions to promote this emerging field is laid out. The Government of Egypt formulated dynamic plans and took many steps such as: 1.

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Establishment of new communities outside the Nile Valley to help relief problems resulting from over population and intensive man-made activities around the River Nile. 2. Nationwide rehabilitation and expansion of infrastructures; typical examples are the greater Cairo and Alexandria wastewater projects. 3. Corrective measures to mitigate pollution problems by adopting the approach of pollution prevention at source, e.g. production of unleaded gasoline to prevent lead toxicity in the population. 4. Conducting Environmental Impact Assessment (EIA) studies including the health component before starting any development project. 5. Creation of a stimulating administrative, economic and legislative setting to attract environmentally sound investment projects. 6. Implementation of the Environmental Protection Law number 4/1994 is an important step towards improving the environmental situation. 7. Health ministerial decrees have been issued with the intention of: (i) Banning the use of lead alloys in the manufacture of any part of grain mills. (ii) Prohibiting the use of empty pesticide containers and recycled plastics in the manufacture of food packages and toys. (iii) Banning the use of PVC plastics in the manufacture of containers of some food stuff. (iv) Updating health standards and specifications of swimming pool water, recreational coastal water and bottled drinking water. (v) Controlling the transport of chemicals by waterways.

Role of the Ministry of State for Environmental Affairs and Egyptian Environmental Affairs Agency Environmental policy statement In early 1991, the government of Egypt decided to prepare a national environmental action plan to strengthen the management of environmental affairs in the country. It was recognized that environmental management must involve multi-sectoral ministries, research and educational institutions as well as nongovernmental organizations in a national effort to prepare an action plan. Monitoring the environment A large number of laboratories are already involved in environmental monitoring, especially in relation to water. However, on the whole, existing laboratories are not well equipped and there is little interlaboratory collaboration. This points to the need for quality control within these organizations to over-

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come the problems, and to ensure an adequate flow of reliable environmental data. Strengthening environmental institutions Responsibilities for environmental protection in Egypt are mainly carried out by the Ministry of State for Environment Affairs and the Egyptian Environmental Affairs Agency (EEAA) in cooperation with a large number of ministries and institutes. They are responsible for: 1) Preparing the National Plan for environmental studies and proposing priorities for implementation. 2) Informing the authorities concerned with instructions and information necessary to implement the National Plan and following up actions taken. 3) Reviewing and drafting environmental legislation after studying similar legislation in developed countries. 4) Proposing standards, specifications and conditions necessary to protect citizens from environmental pollution. 5) Reviewing environmental projects and budgets; and the following-up of their implementation. 6) Managing information programs to increase public awareness, and organizing the exchange of environmental information. Legislative framework The Environmental Protection Law would give the EEAA increased power and duties. The EEAAwould have the power to inspect and to enforce the law. It would also include rules for establishing and running environmental monitoring networks, and would cover the handling and disposal of hazardous wastes. This represents a significant strengthening for EEAA and reflects the government's determination to give environmental protection much more serious attention than in the past.

Role of the Ministry of Agriculture Regulations for pesticides registration in Egypt The use of appropriate pesticides is essential for modern agricultural practices. It is the responsibility of the Ministry of Agriculture to investigate the safety, quality and proper use of pesticides in Egypt. To achieve this, the Pesticide Committee harmonized the national and the international guidelines together in one national framework to become the base of a national pesticide registry procedure. The Committee adopted the World Health Organization classification of pesticides by hazard, the Environmental Protection Agency guidelines for carcinogen

risk assessment, the Codex Maximum Limits for pesticide residues, the Acceptable Daily Intake Levels from the Food and Agriculture Organization, and the proof of registration of the product in the country of origin. The availability of information on efficiency, resistance, quality control, pesticide residue data obtained from field and laboratory trials, mutagenic potential and neurotoxicity are essential for pesticide registration in Egypt.

Role of the Ministry of Health and Population (MOHP) The MOHP being aware of the link between development, environment and health, accorded great attention to this issue and adopted a National Environmental Health Strategy in accordance with the format of regional and global environmental health strategies. The strategy is integrated within the National Health Policy and depends on the collaboration with other ministries, authorities, universities and research centers for taking concerted efforts and decisions required to improve environment and health status. The strategic goal is to improve the health status of the population and enhance health-related quality of life. The strategy addresses priority areas, which require further action to be taken, and means of implementation. The emphasis is on the protection of the population at large from exposure to the biological, chemical and physical factors, which may be present in the different environmental compartments. It will promote a healthy diet, improve food quality, reduce tobacco smoking, improve health education, decrease exposure to harmful factors, improve sanitation, and improve access to primary healthcare. To this end two major initiatives namely, Health Sector Reform Program (HSRP) and Healthy Egyptians 2010 Initiative were launched since 1996. The Health Sector Reform Program is the achievement of universal coverage of basic health services for all its citizens while targeting the most vulnerable population groups. The MOHP is committed to integrate and carry out environmental protection measures at village and district levels through the primary health care system, which is a key element towards achieving an acceptable level of health for all. Training programs were formulated for doctors and nurses to help them handle environmental issues at the community level (Ministry of Health and Population, 2000). The national strategy for health and environment is based upon increasing public awareness of envi-

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ronmental health issues as one of the major elements to help realize its objectives. Education ± at all levels ± and environmental health data are a cornerstone for effective prevention efforts. The Internet has dramatically increased access to environmental information. Databases provide useful information about environmental hazards or other environmental problems in communities to health care providers, policymakers, and the public. Moreover, better dissemination of global environmental health information may reduce the occurrence of disease or exposure to harmful environmental agents. Egypt encouraged environmental health research and launched national campaigns to deal with vital issues related to environmental health problems. Several sectors including health, education, environment, information and religious sectors, were key participants in this effort. The MOHP initiated several programs to combat public health emergencies in high-risk areas, with special emphasis on community participation and intersectoral cooperation to identify real needs and methods of intervention. These administrative structures have branches in all governorates, and receive full support to carry out their functions and contributions to the problems of environment and health. The MOHP is responsible for: 1) establishing standards for water quality which limits inorganic and organic chemicals and microbiological pollutants; 2) monitoring quality and pollutants of surface water (Nile River/main canals); 3) inspecting waste water treatment plants, sampling sanitary liquid waste and industrial discharges; 4) monitoring air quality (SO2, smoke and particulates) in Cairo, and in 56 stations located in 16 governorates; 5) supervising solid waste treatment plants; 6) supervising hazardous waste management; 7) monitoring food safety; 8) developing occupational health standards, and performing hazard investigations, and medical exams for workers.

Healthy Egyptians 2010 Initiative: Environmental health and tobacco control Under the leadership of Prof. Ismail Sallam, former Minister of Health and Population (1996 ± 2001), and through collaboration with the US Department of Health and Human Services and US AID, Healthy Egyptians 2010 was launched on September 29, 2000. Healthy Egyptians 2010 Initiative is a national prevention agenda for disease prevention and health promotion focusing on principle priority areas. It is a comprehensive programmatic approach

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concerned with public health and a conceptual tool to identify the significant and preventable threats to health. Environmental Health and Tobacco Control, Maternal and Child Health, and Injury Control are some of the priority areas in this Initiative. Healthy Egyptians 2010 is a mechanism at the national, governorate and district levels for setting, monitoring and evaluating progress towards meeting national goals and objectives. It is used to focus on public and private sector efforts on addressing specific public health threats. An inter-ministerial, public and private working group has drafted a set of measurable objectives for tobacco control and prevention. A set of strategies including: primary prevention of smoking in adolescents, cessation, health education, media, and a school curriculum are currently under development (Healthy Egyptians 2010 Initiative, 2000). Achieving significant improvement in environmental health and disease prevention is one of the national five priorities in Egypt. The program has objectives related to: 1. Improving air quality through use of cleaner alternative fuels/unleaded gasoline and better monitoring of pollutants; 2. Increasing the availability of safe drinking water; 3. Reducing surface water pollution through better sewer systems; 4. Improving systems for handling medical hazardous wastes. Smoking was identified as being a major public health problem, which needs an integrated approach to control it. In response to the health, economic, and social consequences of tobacco use, a smoking control work plan was formulated in Egypt and put into action starting from 1997. The following criteria have been identified for the success of the Smoking Control Campaigns: 1. Proper identification of the target groups, especially children and adolescents. 2. Addressing young people through the use of peer models, image appeals, lifestyle appeals and simple, clear messages. 3. Utilization of all media channels. 4. Use of the proper dose of information suitable for different target groups. The campaign has been evaluated through conducting community-based survey before and after implementation. Results of the evaluation are used to avoid weak points of the campaign and to incorporate sound strategies into the national tobacco control program. The goal of tobacco control efforts is to reduce mortality and morbidity caused by the use of tobacco products. This can be accomplished through a combination of: 1. Helping those who do not use tobacco to stay tobacco-free; 2. Promoting cessation of tobacco use by encouraging and assisting in cessation efforts; 3. Protecting the health

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and rights of children and adults by preventing involuntary exposure to environmental tobacco smoke. The Ministry of Health and Population has adopted some strategies such as: 1. Preventing smoking initiation especially among youth. 2. Promoting cessation of tobacco use. 3. Reducing exposure to passive smoking. 4. Enhancing antismoking environment. 5. Developing educational programs. 6. Implementing multi-sectoral comprehensive tobacco control approach. As most tobacco control interventions involve behavioral changes and require national coordination, all sectors, ministries, and agencies were involved in the tobacco control plan. The activities from the Ministry of Health and Populations include: 1. In 1997 a Ministerial Decree was issued to assemble a Steering Committee for the National Program for Tobacco Control headed by the Minister of Health and Population. The role of the committee is to develop a national program for tobacco control, define the interventions and activities, identify the role of each ministry and agency, and develop a plan of action for the control of tobacco smoking. The committee comprised representatives from different ministries (Health, Information, Education Social Affairs, Labor, Tourism, Environmental Affairs, Interior and Agriculture) and representatives from Islamic and Christian religious authorities, non-governmental organizations, and from the Supreme Council of Youth and Sports; 2. Issuing Ministerial Decree in 1997 to limit the quantity of tar to a maximum of 15 mg/cigarette and to sample cigarettes periodically and ensure that they are in conformity with Egyptian standard specifications. 3. Prohibiting cigarette advertising through progressive restrictions and related actions to eliminate all direct and indirect advertising, promotion and sponsorship concerning tobacco. 4. Launching a national campaign to prohibit sale of tobacco to young adults and children. This campaign had been conducted during February 1999, and aimed at mobilizing the community to reject sale of tobacco to children and convincing tobacco merchants not to sell tobacco to these groups. 5. In November 1999, the Arab Health Ministers Council discussed a working paper on inter-Arab cooperation on combating smoking in the Arab world. 6. In December 1999, the first interregional focal point meeting for tobacco free initiative was held in Alexandria. To control smoking and reduce the morbidity and mortality rates caused by smoking in the Egyptian society, a comprehensive plan has been developed to be implemented in two phases:

The first phase from 1999 to 2001 included: 1) Reinforcing the smoking surveillance system to monitor smoking trends among different population groups. 2) Putting into action the law prohibiting smoking in closed places. Designated smoking areas will be specified in governmental buildings, hotels, and hospitals. 3) Making all schools non-smoking premises by the end of this phase. 4) Strictly supervising all public transportation to make them smoke free. 5) Establishing smoking cessation clinics. 6) Increasing and sustaining health education messages through press and media. The second phase from 2002 to 2009 includes: 1) Increasing the percentage of smoke-free governmental buildings to reach 100%. 2) Increasing smoking cessation clinic to cover all governorates. 3) Increasing cigarette taxes. 4) Incorporating smoking controls and hazards of smoking in school curricula. 5) Increasing the penalty for smoking in prohibited places.

Role of international conferences and scientific societies The scientific community plays a crucial role in understanding the environmental causes of human health problems, and in collaborating with communities, industries and government agencies in resolving health problems. In collaborating with several scientific societies and government agencies the First International Conference on Environmental Mutagen in Human Populations was held in Cairo, Egypt, January 19 ± 24, 1992 (Au et al., 1993). The meeting sparked the interest in addressing environmental health concerns among scientists in the African Continent and stimulated the organization of the Pan African Environmental Mutagen Society. After the international conference in 1992, the Pan African Environmental Mutagen Society organized the first scientific conference in Cairo, January 23 ± 26, 1993. The theme of the meeting was mycotoxins in food products. The meeting discussed the possible exposure conditions, monitoring methods, hazards of mycotoxins as mutagens and carcinogens, interactions between mycotoxins and viral infections, and different intervention strategies. Subsequent conferences were held throughout the African Continent with different scientific themes: Cape Town, South Africa in 1996 and Harare, Zimbabwe in 1999. The fourth meeting will be organized in Cairo in 2003 with the theme of Children's Environmental Health. These conferences provide the rare but

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crucial opportunity for environmental health scientists and officials in Africa to discuss health issues that are important to Africa.

Future prospects and recommendations It is obvious that the success of the process of technology advancement and economic expansion depends upon the balance between the benefits and the ill effects of such processes. There should be a balance between needs, benefits and risks. Preventing environmental health problems require: (1) having adequate expertise and resources to investigate and respond to such diseases and injuries; (2) monitoring the population and its environment to detect hazards and to provide early warning signals for health problems; (3) monitoring the population and its environment to assess the effectiveness of prevention programs; (4) educating the public and select populations on the relationship between health and the environment; (5) ensuring that laws, regulations, and practices protect the public and the environment from hazardous agents; (6) providing public access to understandable and useful information on hazards and their sources, distribution, and health effects; (7) coordinating the efforts of all government agencies and non-governmental groups that are responsible for environmental health; and (8) providing adequate resources to accomplish these tasks. Development of additional methods to measure environmental hazards in people will permit more careful assessments of exposures and health effects. Despite the great effort made to improve the situation, several actions are still required for environmental protection as outlined below. Putting the measures to prevent and control pollution as high priority Implement and enforce environmental legislation and replace unduly light penalties with appropriate ones; integrate environmental considerations in national strategic planning; provide more resources to monitor, sample, and detect environmental pollutants; finance and manage existing resources more efficiently; expand primary health care through the Health Sector Reform Program for identification and early detection of environmental disease.

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Introducing environmental health impact assessment Environmental health impact assessment of developmental projects, which include genetic toxicity assessment, should be considered. The main objective is to focus on evaluating the health status of the population in the area to be studied: the trends over the past years and assessment of the effect of environmental changes on health. This can be carried through several activities which include correlating the public health findings with the environmental pollution findings (water, air and land); commenting on the standards of public health in rural and urban areas; investigating the major causes of environmentally-related sickness and mortality. Health impact assessment requires to identify the exposure conditions and health hazards; to interpret the health risks by breaking the problem into three main sub-components (1. Vulnerability of community: Who is at risk? The community has several obvious differences in vulnerability. This can include age, gender, economic status or occupation. 2. Environmental factors: Why is the population at risk? Where does the exposure to the health hazard occur? 3. Capability of health protection agencies: What are the health protection agencies doing about the exposure of the vulnerable communities? What could they do in the future?), and to set up a health risk management system (It starts with the planning process. It may simply involve small changes in project operations such as ensuring that the village water pump is properly maintained. It may require technical training to improve simple skills such as handling toxic chemicals or controlling machinery.) Organizing research which should be directed towards applied problem solving Programs to improve environmental health must be based on scientific evidence. The complex relationship between human health and the acute and longterm effects of environmental exposures must be studied so that precise prevention measures can be developed. Surveillance systems to track exposures to toxic substances, such as commonly used pesticides and heavy metals, must be developed and maintained. To the extent possible, these systems should use biomonitoring data, which provide measurements of toxic substances in the human body. A mechanism is needed for tracking the importation of pesticides. Environmental genetics (i.e. the role of genetic factors in affecting individual responses to environmental exposures and the role of biomarkers for risk

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assessment) and cancer genetics should be considered as a broad theme of research programs for several reasons: 1. Genetics is central to research on causes and prevention of human diseases, and plays an increasingly important role in the diagnosis and prognosis of chronic diseases, for which cancer is an excellent disease paradigm; 2. Environmental causes of diseases such as cancer are a growing public health problem worldwide and in Egypt; 3. Environmental genetics encompass research into genetically-based susceptibility and resistance to the harmful effects of environmental toxicants, and thus the concept of gene-environment interaction serves as a context applicable to many disease-specific areas; the application of cancer and environmental genetics raises specific bioethical questions which are excellent models for bioethical issues in genetics in general. Increasing education and training activities The level of awareness in Egypt on environmental issues is low; consequently, an effort will have to be made in education and training. It is necessary to carry out intensive training programs, with distinct objectives, addressing clearly defined target groups to improve public awareness of environmental problems. Well-qualified staff at the central agencies and centers is needed to conduct environmental protection projects in Egypt. Decision-makers' awareness of the importance and dangers of environmental pollution should be enhanced. Public involvement in problem solving, and public acceptance of the environmental action plan costs are very important. This is done by information campaigns in areas where people can eventually act responsibly. On the long-term basis, more comprehensive improvement of the educational systems, further training of special target groups and awareness campaigns are needed. Training should include local environmental bodies, schoolteachers, journalists, environmental specialists and students in primary and secondary schools. In addition, training initiatives are urgently needed to bridge gaps and to help widely disseminate new genetics information throughout the world's biomedical community. Developing and monitoring information systems Developing an integrated monitoring and information system will play a major role in environmental training and education, and in enforcing environmental standards and requirements. For example, the creation of an Environmental Information Center would be a key element for supporting the National Environmental Policy. The proposed cen-

ter would collect, analyze and interpret data, and present information in an appropriate form to different audiences. It can also mastermind the necessary environmental education and public awareness campaigns. It is important to provide appropriate knowledge, especially on a consumer level, of awareness. In the end, the role of the Geographical Information System (GIS) is evident in helping risk assessment and in setting priorities.

Conclusion Many developing countries like Egypt have been aggressively seeking new technologies and industries for economic improvement. However, these activities can also cause environmental health problems. In recognition of these problems, the Egyptian government has organized a multi-ministry effort to address these concerns. Central to these efforts is the adoption of the strategic Healthy Egyptian 2010 Initiative, where environmental health represents one of its four main objectives. Specific issues in environmental health to be addressed are: 1. Protection of drinking water resources; 2. Development of inter-sectorial efforts in controlling urban air pollution, and managing liquid and solid waste; 3. Enforcement of proper use of chemicals; 4. Establishment of an ambitious quality assurance system to enhance food safety; 5. Reduction of noise pollution; 6. Improvement of housing conditions to meet higher health and safety requirements

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