Case study: Using a Health Promoting School approach to reducethe risks from a contaminated environmentin Kosovo after the Balkan conflict.

A Health Promoting School approach used to reduceing the risks of lead poisoning and to establishment of cross-ethnic collaboration.

Ian Young, Head of International Development, NHS Health Scotland

Ardita Tahirukaj, Health Promoting Schools Adviser, WHO Pristina

Geraldine McWeeney, Healthy Environment Programme Manager, WHO Pristina

1. Context

Kosovo is a United Nations Administered Province with Provisional Institutes of Self-Government (PISG) aand is divided into five administrative regions encompassing 30 municipalities.

The conflict in the Balkans in 19989 and also the gradual deterioration of conditions left Kosovo with severe problems in relation to its infrastructure, local capacity and and environment. It also damaged the relationships between the main ethnic groups in the country. HistoricallyAssociated environmental pollution has left a legacy of severe heavy metal contamination in specific industrial areas which are generally inhabitedheavily populated.

As a response to the environmental contamination degradation and it’s impact on human health, WHO, in collaboration with local institutions, is currently implementing a comprehensive programme of activities to raise awareness and decrease exposure to the metal lead and other poisonous poisonous heavy metals by establishing sustainable structures that will address all aspects of this complex problem.Industrial pollution from heavy metal smelting mining activities is one of the main sources of this pollution. Lead in soil analyses taken by WHO in Mitrovica/ë and Zvecan municipalities have shown in over 90% of samplesof cases to be over a safe limit. (Dutch List, 1999reference?)

Kosovo has a population of approximately 2 million people and a very high proportion of the population (approximately 5050%) are of school age and pre-school age. The proportion of children of school age and younger is almost one half of the population and (37 % are under 14 years old)37% are under 14 years of age.

Addressing the lead pollution that affects both the Albanian and Serbian communities is considered as one of the practical ways of unifying the efforts of the two communities in the divided city of Mitrovica/e. This paper outlines how the health promoting school model has played a strategic role in attempting to address the environmental contamination degradation and also play a part in starting to rebuild damaged human relationships resulting from a bitter conflict.

2. The problem

Mitrovica/ë had the largest metallurgic and mining complex (Trepca) in Europe, which commenced activities in 1939 with the extraction of lead, cadmium and zinc. Many industrial plants existed in the complex: a huge lead smelter, fertilizer production plant, refinery, battery factory, zinc electrolysis facility and a sulphuric acid plant. The high concentration and wide range of pollutants released by these industries have produced associated health risks for all the population and particularly children and pregnant mothers. This problem greatly increased as a result of the conflict when little respect was paid to the environment during this period.

The complexes were shut down in July 2000, however, lead and other heavy metals (cadmium, nickel, arsenic and zinc) from the abandoned sites and contaminated soil from the decades of mining and smelting activities have continued to contaminate the environment, and pose a health threat to the population.

Lead is a naturally occurring metal with well established and studied health effects particularly for children. (CDC lead toxicity 2004) Impacts include IQ deficits, behavioural problems, hearing deficiencies, renal impairment and anaemia.

A survey carried out during and after the closing of the plant in 2000 showed high levels of blood lead in the children, adults, and pregnant women in the area. (Molano and Andrejew, 2000).

Preliminary assessments carried out by WHO in 20022/3 of environmental samples show excessive levels of lead and other heavy metals in soil, dust, paint and some locally grown vegetables. The drinking water appears to be within acceptable limits.

A Risk Assessment performed by WHO in 2004 to assess exposure pathways and ongoing impact Preliminary assessment ofrevealed high blood lead levels in children, with those aged two to three years giving greatest concern. The ‘acceptable’ level oofof lead in blood is 10mcg/dL (WHO/CDC). In the areas assessed, old reveal excessive levels, 58% of those tested were above this level acceptable limits in Zvecan, 40 % in North Mitrovica and 15% in South Mitrovica.

This is a serious risk to the health and education potential of the children themselves because the developing brain and nervous system is very vulnerable to damage by lead poisoning. Studies have reported a strong association between high lead levels in children’s bodies and lowered IQ, impaired attention and speech performance. (Needleman, 1993).

The consequences for the potential and future of the population and the area are also serious because of the effects on the developing foetus as well as young children. A pregnant woman high lead levels of lead in her body willcan pass lead directly thisto her foetuschildren through the placenta (Groszek, 20020) and this is especially important in a population such as Kosovo with a high birth rate. Lead can stay in bones for 30years and during times of increased calcium needs, such as in pregnancy, an increase in the release of lead from the bones can occur.

Due to the consequences of the conflict and a subsequent lack of financial investment there are significant physical infrastructure issues to be addressed in Kosovan schools. These include some schools not being completely weather proof and schools working up to four shifts of students per 24 hours.

The above problems are particularly acute in Mitrovica/ë (e) where the displacement of population has resulted on great pressure on school buildings. However, despite the issues of a poor working environment for many students and teachers, and the modest salaries of teaching staff, there is a positive and purposeful atmosphere in the schools visited and great energy to improve the situation. This probably relates to the fact that improvements have occurred and that there is an expectation that Kosovo’s political status will be resolved in some way soon. Some new school buildings have been provided and there is considerable pride in this achievement, although maintenance budgets are limited.

3. The Response - Building the Health Promoting School network

WHO in collaboration with local institutions are currently implementing a programme of activities in the Mitrovica/ëe area with funding from the Dutch and Norwegian Governments. This aims to decrease exposure from environmental pollution caused by heavy metals and to raise the awareness of the population. This programme of work through local capacity building and working groups include health risk assessments, a public awareness campaign, the development of a health strategy (screening, diagnosis and management protocols) and environmental remediation activities. WHO also established fourthreelocal cross-ethnic and inter-sectoral working groups focusing on health, health risk assessment, and a public awareness campaign and risk management.

The Health Promoting School approach was chosen by the public awareness working group, as a main tool for raising awareness of the population on how to live more safely in a contaminated environment. through schools strong potential in creating links between school-home and community due to a respectability and influence of teachers in the society.. The public awareness working group includes officials from different sectors such as health, education, environment, women’s associations, The Institute of Public Health and The Trepca Institute. Both ethic groups, Albanian and Serbian, are represented on this working group.

This multi-sectoral method of implementation aims to improve the environment of schools through environmental health risk management activities (cleaning and greening activities)., but. iIIt also raises awareness in the community and local institutions to environmental problems, their health effects and methods to decrease exposure and minimize risk during exposure. Building the capacity of health and education personnel and providing opportunities for professional development has been shown to be an effective strategy in the development of health promoting schools in other countries (Young, 2002).

It is not possible in this short paper to outline all of the strategic work which has been undertaken but it is important to understand that a multi-sectoral approach has been used and that capacity building has been undertaken at the national, municipal and school levels.

For example at the national level, an Inter-ministerial Committee on Health Promoting Schools has been established and this committee includes representatives from Ministry of Health, Ministry of Education, Science and Technology, Ministry of Environment, Institute of Public Health, Ministry of Youth, UNICEF, IOM and WHO.

A memorandum of understanding on health promoting schools was formalized between The Ministry of Education, Science and Technology and The Ministry of Health and Ministry of Environment and Spatial Planning in order to:

  1. develop policy and ensure inter-ministerial collaboration in the areas of health education and health promotion;
  2. promote a healthy school environment, where pupils can acquire new knowledge and skills;
  3. and improve and strengthen the partnerships between the school, parents and community, and all agencies having a positive role in their welfare. (Figure1)

Kosovo has a relatively small but very active network of health promoting schools with the support of these four government departments, a national co-ordinator and a national co-ordinating committee with all key stakeholders represented. Kosovo has developed a progressive, flexible school curriculum which has the potential to provide an excellent framework for health education and promotion in the future. There is a great opportunity to develop a health education curriculum which is fit for purpose because of these reforms, and there is recognition among senior staff in the Ministry of Education Education Ministry that this is important for the future of Kosovo and its young people.

There is also a well established network of UNICEF ‘Child Friendly Schools’ which is also a whole-school approach to the health and welfare of young people. In addition there is a UNICEF lifeskills programme which is a curriculum-based initiative with a strong health component. In relation to research, there have been topic-specific research surveys undertaken in Kosovo relating to specific topics or identified problems eg substance use, blood lead levels.

The European Network of Health Promoting Schools (ENHPS) has considerable experience in building sustainability into the programme. Kosovo has managed aspects of this very well and the next stage of this will be to increase the number of schools in the network. The UNICEF Child friendly schools initiative has built a larger network of 130 schools and they are now sharing ideas with the benefiting from the ENHPS group and acquiring experience ofexperience in building sustainable programme within schools.

The core values of the new partnership initiative could be summarised as follows:

  • respect for self;
  • respect for others (ethnicity, religion etc);
  • respect for the environment;
  • utilising a whole-school approach. Links with:

curriculum

family

community

other specialist agencies including health sector;

  • respect for life-long learning - this has great potential with the age distribution of the population;(370% of Kosovans are 15 years and younger).
  • based on a belief that only healthy individuals can fully benefit from education and that education can develop life skills and health literacy.

The health promoting schools initiative is being developed within the context of a logical framework document developed in Kosovo and this is an important step forward in linking the vision of ‘full physical, psychical and social well being for all students of Kosovo’ with strategic objectives and indicators of achievement. However this will need to be further developed and revised as some of the indicators of success appear too modest eg ‘until 2017 all schools have drinking water and sanitation’ This is a basic public health provision/entitlement that needs more urgent attention. Kosovo will be looking at new developments within the European Network of Health Promoting Schools which has been exploring indicators of effectiveness and provides case studies from a range of European countries. (Barnekow et al, 2006).

There has been a considerable investment in training. For example a four day multi-ethnic training seminar was organized for teachers, school directors, representatives from The Ministry of Health, Ministry of Education, Ministry of Environment, The Institute of Public Health, women association representatives and representatives from Trepca Institute. This event was also of considerable symbolic importance as it was the first time representatives of both communities had trained together in any educational sphere since the conflict. The objectives of this training seminar organized by WHO were as follows. To:

  • train teachers, school directors and key stakeholders in the health promoting schools approach and include specific reference to the issue related to the heavy metal contamination of the environment;
  • raise awareness and generate the support of community stakeholders;
  • trial the translation of the training Manual ‘Promoting the Health of Young People in Europe’ (Young and Williams, 1994) and associated training methods.

As part of the capacity building of local professionals who were working in the public awareness campaign, a study visit to Slovenia and Poland was organized. The purpose of the visit to Slovenia and Poland was to develop links with institutions in Slovenia and Poland that are involved in field of environmental research, environmental remedial actions and public awareness programmes.

At school level the appointed co-ordinators and teachers received training whichtraining, which included the following:

  • Identifying ways to include environmental health in the school curriculum.
  • Exploring methods such as ‘starting from where children are’ (Wetton and McCoy, 1998) regarding their knowledge on environment pollution and reviewing how the school, children and their families can contribute to improving the school and community environment.
  • Helping schools to make links with parents, mothers groups and health personnel.
  • Exploring technical issues such as nutritional approaches to reducing the anaemia which is associated with lead poisoning.
  • Exploring technical issues in reducing exposure in the children’s home environment and in the school and its immediate environment.
  • Improving community participation in solving environmental health problems.

As part of the capacity building of local professionals who were working in the public awareness campaign, a study visit to Slovenia and Poland was organized. The purpose of the visit to Slovenia and Poland was to develop links with institutions in these countries that are involved in field of environmental research, environmental remedial actions and public awareness programmes.

4. Conclusions

This programme is at an early stage but considerable progress has been made over the last four years. The health promoting school model has been shown to be suitable as a basis for developing the approach to a highly specific problem such as children being exposed to an environmental hazard. This relates in part to schools being an excellent vehicle to reach the at risk target groups of children and pregnant mothers. In addition the parents, the children’s environment and the health services are accessible through the schools. The educational role of schools enables initiatives to be pursued relating to minimizing exposure to the pollutant in the young peoples’ environment. The whole school approach can also play a part in minimizing the effects of exposure on the body through various strategies. For example through appropriate nutritional advice and food provision in schools, the risks of the anaemia associated with lead poisoning can be reduced. The activities in schools also generate media coverage of the heavy metal pollution which helps to reach more of the general population.

However the model of this development is not merely about schools being a convenient venue for public health initiatives. This is not a short-term project but a sustained attempt to integrate education and health issues for the benefit of young people in Kosovo. The Kosovo HPS strategy has been developed for the years 2007 to 2017, and the health promoting schools programme is also included in the Kosovo Education Policy/Strategy as well as in the Kosovo Development Plan for 2007-2015. The strategy has been developed by an inter-ministerial committee with the participation of schools and young people. The strategy also integrates related initiatives such as Child friendly schools and life skills with violence prevention and mental health promotion under the overarching concept of health promoting schools.