“AS FAR AS WE CAN DETERMINE:” HELPING TO PUT THE BHS SAGA INTO PROPER PERSPECTIVE

Before I begin, I would like to state for the record that this is my opinion in my personal capacity as a concerned citizen and as an alumnus of the BHS, and not as a member of the Medical Board, Medical Association, or Ministry of Health. Given that I was vocal before and that I was one of the four on the arbitration committee, I feel it is my duty now to put in writing, for the record, some of my thoughts on the NIOSH report now that it has been made public.

My major concern in all of this was, is and will always be the health and safety of the students and teachers at the institution. Being a medical doctor, it was imperative that the root cause of the symptoms of the students and teachers at the BHS be diagnosed, so that remedial action could be taken, if possible, so the grounds could be reoccupied again, if possible, without any recurrence of the same complaints from the students and teachers that prompted this saga in the first place.

For me at least, before, during and after the arbitration exercise, the foremost issue was the intermittent detection of hydrogen sulfide gas (H2S) by the CARIRI team. Although CARPHA subsequently claimed that the levels were within the safe limits according to international standards, CARIRI’s data of spikes at certain locations and at certain times required an explanation, which was not “determined” by CARPHA then and which I hoped would have been “determined” by the NIOSH team now, this in light of similar official reports of similar symptoms being reported and associated with H2S at other schools in the region and overseas. (Please see: Several students complain of sickening smell a week after Central High School campus reopens, Executive Summary Operation Breath Easy II, Parents at Boulder’s Casey Middle: Shut school down until gas problem fixed, Teacher surveys, air quality monitoring show few concerns at Boulder’s Casey Middle School and Investigation of an Outbreak of Unusual Skin Rash at a New School.)

Here were some of my thoughts on this thorny issue of H2S gas which were posted on the SKList on June 12, 2015:

“I was having a conversation with one of my patients recently about the BHS situation. He is over 90 years old so I gathered he would know what the site was used for before the BHS was built, and he told me it was an estate where the effluent from the sugar factor was dumped. I am not able to corroborate this, but if this is accurate, does anyone know what the effluent consisted of (sewage or other chemicals), and would over the years there have been interactions with the sewage system contributing to episodic release of H2S?

The question is how do we go about investigating this? If the soil is contaminated, do we need to discard the soil on the grounds, replenish and rebuild? I am eagerly awaiting the NIOSH report. I hope they took the required soil samples and did the requisite continuous air testing. Given the episodic release of H2S found from CARIRI’s report, anything less than continuous air testing will be inconclusive.

Although the volcanologists have ruled out a geological source for the H2S and symptoms, I am still not convinced again given the lack of continuous measurements.

At a minimum, if we are serious in finding a causative factor, we have to have continuous measurement over a period of months to years, to make any definitive conclusions. Also, if there are dynamic interactions with the sewage system and the soil to produce the H2S, testing when the school is closed and sewage systems not being used, may produce false negative results.

Continuous testing should have been ongoing when the students were there to delineate any pattern or lack there off. I am not sure what this would mean going forward. Also, I hope continuous monitoring of symptoms at the WHS is still ongoing to determine if the symptoms are environment, host or agent specific, i.e related to the site or related to the students and teachers.

We need to have wider consultations with stakeholders in bringing closure to this issue. This should not be a political issue, as the health and safety of our students and teachers is a public health issue. More resources should have been provided by the Ministries of Health to do the continuous monitoring of symptoms and monitoring of air and quality of soil, if we are serious about these matters.”

In a follow-up email on the SKNList that day, I continued:

“This issue may be bigger than the BHS. If the wider area was part of the estate, where exactly was the dumping of the effluent located? Was it concentrated near the BHS? What about the surrounding area? Until we do a comprehensive analysis of the grounds and the environs, we will never find out.

We have a high incidence of cancers, infertility, and allergic conditions in St. Kitts. It would be interesting to see if attendance at the BHS can be epidemiologically linked to these health issues. There are other possibilities. (I also attended the BHS so I also have vested interest in finding out the answer to these questions.) Until we are able to fund epidemiological studies of this kind, we will continue to speculate and get nowhere. Hopefully, the Ministry of Health is willing to reach out to our regional institutions and engage them in a long-term study to determine the causes of these important health issues. As a colleague always tells me, it takes cash to care. I hope we can prioritize our cash flow to deal with this most important issue.”

That was about two months ago.

Having read and studied the NIOSH report, here are some observations that were made:

1) The school was unoccupied during their evaluation.
2) They saw visible water stains in some buildings, which suggested past or current water infiltration, this at a time when we are experiencing a very dry spell with minimal rainfall, and possible under conditions not representative of the time when the school was occupied.
3) This was an INDOOR environmental quality evaluation, although some of the PREVIOUS concerns were related to 1) high H2S spikes at several OUTDOOR locations, and 2) contaminated soil possibly related to malfunctioning sewage and soak-away pits, some of which were even discovered after the CARIRI and CARPHA reports.
4) H2S was measured only in ONE location in the chemistry laboratory over a short period of time.
5) They highlighted other variables, which were not considered in the previous reports, such as temperature, relative humidity and mechanical ventilation issues (although these were assessed when the classrooms were UNOCCUPIED).
6) They advised to “STOP ANY ADDITIONAL ENVRIONMENTAL AIR SAMPLING AND PROPOSED SOIL SAMPLING FOR BACTERIA.”
7) Given the non-specific symptoms of the students and teachers and a “smoking gun” agent was not found during their evaluation, they focused primarily on a hierarchy of controls approach, from engineering controls such as proper and adequate mechanical ventilation, moisture/mold mitigation and pest control, to administrative ones.
8) They encouraged a proactive approach with collaboration among administrators and employees and provided links to official documents on mold issues and its mitigations.

Initially, on first reading, I was disappointed that the evaluation was not as comprehensive and extensive as I had expected for an international body, as I thought more continuous monitoring of the air quality, not only indoors but outdoors along with soil sampling were warranted to get to the bottom of it all, to determine if it was safe to RE-OCCUPY. Also, they were making inferences on readings that occurred when the school was not occupied and hence the integrity of the sewage and soak-away system were not operational and “stressed.” Also the temperature and relative humidity may become much higher than recorded when you have warm and sweaty bodies in a room with inadequate ventilation.

Having read other evaluation reports at other schools and the challenges involved, and knowing from my professional practice in medicine that many nonspecific clinical symptoms and signs have causes that are multifactorial in nature, involving host, agent and environmental factors, I have now come to accept the WISDOM of the report in focusing LESS on the host and agents which we may not be able to identify and control, and focusing MORE on the environment which we should be able to control. I have also been seeing similar complaints, but with not as much scrutiny as the BHS, from other schools and other institutions, and successfully dealing with mold and ventilation issues were what I most recollect were able to alleviate the intensities and frequencies of their symptoms and signs.

To do continuous indoor and outdoor air quality and soil analysis is going to be costly, and is going to take resources from other areas, which could have been used for more essential services. Given that there are infrequent episodes of H2S spikes and mold infestations that may have been responsible for the unpredictable timings and severity of the symptoms, a proper ventilation system and proactive approach for water leakage and mold infestations buttressed by a more trusting and collaborative approach among all stakeholders appear to be the most cost-effective and prudent way forward.

As a medical doctor, when I see a challenging patient that has become a diagnostic dilemma, I always ask myself two questions: 1) Why this patient and why now? and 2) Are we dealing with individual, situational or systemic factors?

Looking at the responses on social media to the NIOSH report, it appears that many are of the opinion that the answers to the two questions above are political in nature, since a “smoking gun” agent has not been found, and they are now claiming that the teachers, students and the present government were probably creating mountains out of mole hills of nonspecific symptoms for political gain. I have also been accused of being complicit in this scheme.

I beg to differ. Although there may have been political fallout due to this being a major issue of national importance, which no doubt it was and still is, many infrastructural and community deficiencies have been identified and addressed along the way, as it pertained to mold, the sewage system, soil contamination, ventilation and preventative-maintenance issues, that have had major bearings not only on the BHS, but should have bearing in ALL institutions inclusive of other schools and public government buildings. As a citizen and a medical practitioner, I have learnt many things along the way, and although, “AS FAR AS WE CAN DETERMINE,” no “smoking-gun agent” was identified, a “smoking-gun” environment, of high temperatures and relative humidity in a culture of inadequate and improper mechanical ventilation and preventative maintenance, was identified in this report.

Why the BHS out of all institutions? It is possible that being the biggest school in the Federation, it would have produced the largest number of students, and would have been the figurative canary in the coal mine to cause a significant amount of people developing symptoms to warrant attention and investigation.

Why now, and not 10 years ago, or 10 years from now? First, given global warming and climate change, the relative temperatures and humidity may have changed favouring faster growth and spread of mold and their possible toxins. Secondly, given the malfunctioning sewage and soak-way pits, and the overcapacity of the school (where 800 students and 80 teachers were on a compound “designed to house 300 students”), leakage of sewer gas and soil contamination was inevitable, and it was only a matter of time. Also we did not have a preventative-maintenance policy at this institution, or as a matter of fact, any other. It must also be noted that most of these investigations were done after significant remedial action were taken, and coming to the conclusion that “nothing was wrong” in the first place, is like cleaning a crime scene after the event, and finding no evidence afterwards, and then claiming no crime was committed in the first place. This is at best disingenuous and at worst very, very dangerous and unforgiving.

Thirdly, it is possible that we are getting an increase in susceptible individuals now, which is more than what it was in the past. Given the fact that overweight and obesity is on the increase, and our diet and lifestyles are become unhealthy, I would not be surprised if some of the increase in complaints may be due to increasing hypersensitivities to common allergens like molds and other toxins in the environment.

Fourthly, and most important of all for me, issues of national importance like this spilled over into the political spheres, where it should not have gone, simply because of the absence of a viable and functioning Medical Association at the time. Our profession should shoulder some of the blame. Given the frustrations of the students and teachers, and our absence, to whom they could have turned to for support and help to MEDIATE and address their medical concerns, the government of the day was forced to stand their ground, and the opposition had no choice but to lend their weight in defiance of the stance taken. This is only one health issue of public importance, which our medical fraternity has disgraced themselves and has embarrassingly dropped the ball, as we should have been involved from day one, to prevent this national public health issue from becoming a political one.

If civil society do not rise to the occasion and advocate for issues, be they medical, legal, policing or ecclesiastical in nature, then inevitably the issues sooner of later will become political ones. We should not blame the politicians for failing because of lack of effort on our part. The sooner we realize that we in civil society are the engines of harmony, conflict resolution and sustainability, the better we as a nation will be. (I am happy to report that we have revived our Medical Association since late last year, in our effort to become more accountable to our communities, which we have come back home to serve.)

The million-dollar question now (pardon the pun) is where do we go from here? It is hoped that all stakeholders would read and reflect on this NIOSH report, as they are the foremost agency of occupational safety and health in the world. They have provided a roadmap to guide us in plotting a way forward. Although many things were said on the political platform, an honest discussion of the real costs and benefits of either reoccupying or relocating needs to be readdressed. Hopefully, we can begin to rebuild trust in our schools and among its administration again, so that any decision taken in going forward will be done in the best interests of our students and teachers.

In the spirit of goodwill, transparency and accountability, and with God’s blessings, hopefully we can create and nurture open channels for sharing of verifiable information for a healthier and safer working and learning environment, so that we can recreate a conducive environment built once again on the PRINCIPLES of mutual respect, mutual caring, and above all, mutual trust, and be once again true to our founding motto, “PRINCIPIA NON HOMINES”