The Urban Poor: reality, risks, and solutions to healthcare problems

India is a country experiencing extreme demographic change.  While seventy percent of its people live in rural areas this figure is rapidly changing as people move to cities I search of better economic opportunities, making the urban sector the fastest growing population in India. Of the 300 million people living in cities, a third are in slums (3).  The plight of this urban poor is drastically different to the middle classes, or even the rural poor.  Extreme population density and a lack of sewage system makes these slums a center for disease and other health risks associated with a lack of clean water and sanitation.

The effects of the slum are evident in children mortality statistics; compared to urban or rural children, the urban poor are at extreme risk.  While the Infant Mortality Rate (IMF) for urban areas was about 48 (per 1000 live births), this number is almost 50% higher in slums at 73 deaths per 1000 live births.  This is an indicator of both infant and maternal health.  The conditions that the women are living in are directly affecting the health and growth of their children.  The controversy with slums and government intervention is that the government does not want to encourage these settlements by providing services, but the severity of the health impacts can reach beyond the slums such as spreading disease.  Currently, 30% of urban areas in Delhi have no access to sanitation whatsoever.  With open sewage in streets and not even a field to dump it in, residents are existing in their own filth.  Runoff takes this contamination into the water supply, which creates further health impacts for those living in the slums and also those living downstream (3). 

Another impact of slum development is the necessary land-cover change that takes place and the range of infectious diseases that follow.  When outlying land is deforested for shelter, fuel, and space, there are a number of environmental consequences which precipitate human morbidity and mortality.  By changing the size, shape, and distribution or these “wild” land areas, humans come into greater contact with wild animals and pathogens (1).  It has been determined that HIV was spread through an interaction between primates and humans; it is possible that proper land management and development would decrease the chance of a new worldwide pandemic disease crossing over from animals to humans.  Other less dramatic diseases do occur at greater rates in recently developed land areas; malaria is carried by mosquitos which breed in standing water.  Wetland modification projects would expose a greater number of people to a high risk of diseases carried by mosquitos including Malaria, Dengue fever, Japanese Encephalitis, West Nile virus, Rift Valley fever, and Yellow Fever (2).  These are just a few diseases which occur do to land development and are particularly pandemic in slums, where exposure is high and health care opportunities are scarce, inadequate, or sometimes dangerously ignorant.  The best solution is for the government or an NGO to somehow provide basic health care and sanitation to the urban poor.  This will benefit both the slums, but the health effects which emanate into the cities.

Currently, the greatest challenge to slum healthcare is an availability of doctors, a system of distribution of medical services, and the means of the people to pay for these treatments.  One popular proposed solution is to use medical students as the primary care givers, equip them with vans, and have the government pay for certain healthcare needs (3).  There is a mutual benefit for the medical student who would work in these areas; the students would gain useful and “real-world” knowledge while still providing informed care to the patients.  Additionally, as part of their medical training this work would go unpaid and not cost the government or the patients anything.  The vans are a relatively cheap and upfront investment.  They give the project momentum and encourage the active participation of medical staff in areas they would otherwise avoid. Lastly, the medical supplies paid for by the state would be basic but could mean the difference between life and death for millions of urban slum dwellers.  Vaccinations for infants and children alone would make a marked difference in IMR and under 5 mortality rates, and this cost may even be covered by United Nations grant money.

So, while the issues of the urban poor are complex and many, there are a few fundamental changes which could quickly and cheaply be made to increase the quality of life in India’s cities.

References

1) Earth materials and health: research priorities for earth science and public health (pp. 99-111). (2007). Earth Perturbations and Health Impacts. Washington, D.C.: National Academies Press.

2) Mosquito-borne diseases, infectious disease information, NCID, CDC. (n.d.). Centers for Disease Control and Prevention. Retrieved September 23, 2011, from http://www.cdc.gov/ncidod/diseases/list_mosquitoborne.htm

3) Yadav, K., Nikhil, S., & Pandav, C. (2011). Urbanization and Health Challenges: Need to Fast Track Launch of the National Urban Health Mission. Indian Journal of Community Medicine , _. Retrieved September 23, 2011, from http://courses.furman.edu/mod/resource/view.php?id=106513

Microcredit and Women's Empowerment

My particular approach to politics and life often leans towards a focus on smaller, more local solutions to problems.  It may have something to do with being raised in a small town and in a small state, but the local approach of microcredit and “village banks” seems like a near-perfect model for lifting people out of poverty. What makes this model so impressive is its ability to pool capital, create bonds of interdependence between women, empower women to make major decisions in and out of their households, and to accomplish this without becoming indebted to their husbands or major banking corporations. 

The heart of these “self-help groups” or SHGs is regular village women; they are historically proven to be more productive with funds from loans and they repay the loans at a rate of 98% (Thomas and Sinha, 2009) and make the women safer from an investment standpoint.  This may be for a variety of reasons, either they are more committed to providing for their families than their male counterparts, or are under greater social pressure to fulfill their roles as caretakers.  It is thought that when the financial agreements are between village women, there is a conscious or unconscious feeling of peer pressure which keeps the women honest and prompt in their repayment.

The main goal of microcredit is for a community to provide a small loan to a woman looking to make an investment that will offer a return and lift her family out of poverty and all that goes with it (Kothari and Gupta).  For example, if a young mother were to accept a loan and invest that money into a small from-home business, she may be able to support herself and her family.  With this financial independence she has options: if her husband is unjust in his treatment, she can leave him without worrying her children will starve; she can send her kids to school and offer them a better opportunity than she had herself; she can make choices, which is probably a power she has never had before.  This seemingly simple power has some unexpected consequences (Thomas and Sinha, 2009).

SHGs have a very positive effect on the mental health of women.  When the women meet in a group and discuss their issues (not just financial) they create a support group for each other.  By seeing that their opinions and input have merit, there is a noticeable growth in self-esteem.  This can go a long way in treating mental imbalances like depression.  Just knowing that she is not alone in her struggles, a woman can overcome a variety of other pressures coming from her family and community.  This self-esteem can be an observed and learned behavior for this woman’s children.  If they learn from their primary caregiver that she is a strong woman worth respect, it will breed an entirely new generation, one with a few less prejudices.

If these self-help groups are so glorious and perfect and wonderful, you would wonder why not everyone would be crawling over themselves to be a part of them.  While the village banks are a center of support, they can also be a source of exclusivity.  When the women agree on who is to receive a loan, unmarried or older women are often marginalized.  The SHG creates its own rules and prejudices; a hierarchy of who is more deserving means that some women are still outcasts to a degree.  Then, there are the women who do not get to participate in these SHGs at all.  Women who either work so many hours they cannot make the time to attend, or are from such a lowly caste that they would not be accepted. It is unfortunate because these are the women most likely in need of financial help and companionship (Thomas and Sinha, 2009).  It is also the sake, that many of these village banks are investing their money in projects which do not reap long term reward.  Women are asking for money to repay previous loans or to purchase dowries.  There is still a positive social effect, but it does nothing to financially lift these families out of poverty (Thomas and Sinha, 2009).

Microcredit is a novel idea which has far reaching consequences in establishing social and financial opportunities for women. Since its inception in the 1980s, it has served to lift some people right out of poverty, and the magic of this is that they are doing it almost entirely themselves.  What other people are being held back based on their sex or social position?  If we can further facilitate the growth of these self-help groups, then we can give women an opportunity to remake poverty in India. 

Sources:

Kothari, V., & Gupta, N. (n.d.). Micro Credit in India: Overview of regulatory scenario. Micro Credit in India: Overview of regulatory scenario. Retrieved September 15, 2011, from www.vinodkothari.com/Micro%20Credit%20in%20India%20-%20Overview%20of%20the%20Regulatory%20Scenario.pdf

Thomas, R., & Sinha, J. W. (2009). A Critical Look at Microfinance and NGOs in Regard to Poverty REduction for Women.. Social Development Issues, 31(2). Retrieved September 13, 2011, from http://courses.furman.edu/mod/resource/view.php?id=103026

Economic, Social, and Political Implications Arising from India’s Water Crisis

India is a country whose dependence on water is growing even more quickly than its population.  With monsoons, floods, and droughts occurring with such regularity, there are those who face extreme difficulties in handling how much water do or do not have.  While floods come as regularly as the monsoon, arid land is facing such water scarcity that the future for entire states looks bleak.  Since independence, water per capita has dropped from 6,008m³ to 2,384m³ as of 2000 (Singh, 2007).  Due to increased population pressure and industrial and agricultural innovations, India is neither capable of harnessing enough water to provide for its entire people, nor is its infrastructure capable of preventing massive rainfalls from causing extreme devastation.

Floods are particularly troubling in India because of the regular destruction they wreak, costing on average 1,600 lives a year, as well as homes for more than 30 million people and 8 million hectares of agricultural land (Singh, 2007).  Starting with the economic effects, this is a massive amount of land left unusable; it is only the technological advances which began in the Green Revolution that keep India’s agricultural productivity up, while accounting for lost land means that there is truly little growth.  What does this mean for a growing population who has stagnated in their food production?  Future floods could lead to loss of enough cropland to send India back to the days of famine.  Without the ability to work the land, millions are left displaced and have no resources to rebuild with.  This can have a fallout effect in regards to health, education, and social stability in rural India.  However, flooding is not limited to rural areas.  Urban flooding is common due to the number of impermeable surfaces seen in cities.  Poor infrastructure and the sheer amount of water that is deposited during monsoon rains means that the water often has nowhere to go but into streets and buildings.  The damage caused by this constant flooding puts a great deal of economic pressure on city-dwellers, and may affect their choices in regards to budgeting for medical treatment and education.  The link between environment and social stability is clear.

Droughts have other implications and problems for India.  Areas that are identified as water stressed or scarce are the most likely to be affected by drought, and these tend to be arid or semi-arid areas (Singh, 2007).  Rajasthan is an area particularly affected by both drought and subsequently groundwater depletion (Singh, 2007; Rodell, 2009).  The arid nature of states like Rajasthan and the industrialization of agriculture to include massive irrigation, makes what was once a more nomadic but stable area into a population dependent on a constant water supply in an environment which is prone to drought (Rodell, 2009).  Data from the GRACE satellite has proven that groundwater in the area is being depleted at a rate of 17.7+/- 4.5 km³yr^-1 (Rodell, 2009); this area includes major metropolises like Delhi and the wealthy state of Haryana.  Lack of water to these states and territories would be extremely destabilizing to the entire country as major centers for wealth and government.

Singh presents two possible strategies for dealing with water distribution issues.  Broadly, India could choose to deal with water issues with a structural approach or a non-structural approach.  In cities, it may be prudent to increase structural solutions like dams, canals, and drainage.  Cities are not going to disappear due to natural disaster, no matter how prudent (look to New Orleans and Katrina).  It is better to protect the cities while harnessing the benefits of dams and reservoirs to provide for the power and water needs of the population living there.  For more rural areas that are experiencing greater scarcity, the solution may lie in non-structural solutions like emigration.  If an area is no longer capable of supporting life, people will move on their own accord eventually. It makes sense for the government to support this to try to prevent issues that often result from movements or environmental refugees.

How India deals with its water in the coming decades will make or break the entire country.  With a booming population and increasing temporal and spatial water displacement, India will be affected from the bottom up in its economic power, social stability, and strength of government.  If water issues are allowed to progress to the point of acute crisis, the center of India’s government in Delhi will be facing such a shortage that it will be unable to take action to help the country. Action must be taken now to have a positive and lasting effect.

Water: How temporal and spatial distribution affect health in India.

The issue of water as it impacts both health and environment in India is complex.  The large population requires a vast amount of water, but the spatial and temporal distribution of this resource is often to the disadvantage of the people. They have tried to overcome this shortage by drilling tube wells, shallow wells that are reaching ground water that is quickly becoming depleted or filled with harmful elements like arsenic.  Now, one of the most populated countries in the world is facing a water crisis driven by both urbanization and geology.  The policy which is established both by India and the surrounding countries will largely impact the social and economic face of the region.

The monsoons are an essential to both urban and rural life in India. The south Asian monsoon brings life-giving rain to the Indian subcontinent in just a few short months; when the monsoon fails, the consequences are largely drought.  This means little water for irrigating crops or replenishing ground water. This problem can easily begin to perpetuate itself.  With no rains, the wells get even more overused, which further lowers the water table.  This leaves the underground aquifers open to poisoning from elements like arsenic or pollution from other ground sources normally kept at bay by the pressure of the aquifer (Dissanayake et al, 2010).  Arsenic and other chemicals have obvious and harmful effects on the populations; “hyperpigmentation, melanosis, plantar and palmer keratosis, carcinoma of the hand, and oedema of the legs” are just a few serious health problems which are result of consuming food or water containing high (though naturally occurring) levels of arsenic (Dissanayake et al, 2010).

While India is blessed with over 120 cm yr^-1 of precipitation a year (the highest of any other country), the temporal and spatial distribution of this water is extremely limited, which leaves many states in India suffering from drought and ground water depletion (Rodell, 2009).  The monsoon’s effects are limited by geography.  In the region east of the Western Ghats, the high mountains do not let the rains pass and the area has become a veritable desert.  Other states have suffered from similar lack of rains or that they simply come in too short of a time period.  When such a massive amount of water appears in just a few weeks, the result is flooding; it is simply impossible to capture that amount of water and keep it to be dispersed over the year.  Instead, India experiences flooding which serves to further contaminate water systems as fresh and sewage water are mixed together.  These are examples of unequal temporal and spatial distributions.

With groundwater in India being depleted at an average of 4.0cm +/- 1.0 cm a year in northwest India, the problem could also become political as the border states rustle with Pakistan for control of more groundwater (Rodell, 2009).  As a matter of policy amendment, this may be a prime opportunity for India and Pakistan to come together to provide more fully for their citizens and resolve some political tension.  There would be a great reward to both governments if they sponsored the aid which relieves these regions.  As Akissa Bahri noted in his article in 2008, “in addition to enjoying a higher quality of life, healthy citizens are more economically productive.  Experts estimate that inadequate access to water costs sub-Saharan Africa some $23.5 billion dollars a year.” While Bahri’s article focused on sub-Saharan Africa, the same principles of cause and effect can be seen and applied in India. In Rajasthan, Punjab and Haryana, 95% of groundwater depletion is due to agriculture and irrigation (Rodell, 2009).  This means that only 5% of the water use would need to be subsidizes by the government to provide cleaning water for domestic use.  If Bahri is correct, this could dramatically transform the economic performance of the region and grow and return the government’s investment in that area.  If these governments do not act appropriately, it could lead to further political degradation between them.  With no relief offered to these areas, these states will once again become grounds for massive movements of refugees, but this time it will be because of environmental causes.  Can India afford to displace so many of its citizens? Again?

The political, economic, and social future of India is largely dependent on its citizens’ access to water.  By providing water in areas of scarcity or poor quality, India could solve many of its health problems, which would boost the economy, and lead to a more stable country.