( By Radhika Ramasubban, Bhanwar Singh & Nigel Crook )

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Poverty, Enviornment And Disease In Bombay


The health problem in a city like Bombay are caused by the spreading of insanitary conditions, and uncontrolled industrial and commercial activity in the big factories and in the small workshops, which result in pollution.

The supply of public goods and services by the Government and Municipality has not kept pace with the growth in population, particularly for the slum dwellers. The increase in drinking water supplies from the reservoirs has taken place once every fifteen years or so, barely catching up as the situation gets rapidly worse. The laws against water pollution ( for example the 1969 Act) are mostly ignored, and it may be noticed that sewage is still being emptied into water courses like the Mahim creek which flows alongside major slum colonies. The policies concerning water and sewage do not touch the living conditions of those living in hutment colonies.

Money spent on housing for the poor has not even reached the planned targets. Schemes to upgrade slums have not usually included the pavement dewellers or chawls in the inner city. These make up about 17 per cent ( nearly a quarter ) of the poor households in the city. So it could be said that for some of the poor, housing conditions have improved a little, but for the rest they have actually got even worst. One can agree that although there have been some improvements, altogether the environment of large sections of the poor households has not been made better, inspite of public expenditure on drinking water, disposal of wastes, and upgrading of slums.

Unlike poor people in smaller towns and in rural areas, the poor in Bombay have no means of getting fuel free of cost, and must rely heavily on kerosene. Half of this has to be bought at black market prices as the supply from the ration shop is inadequate, and many households are not entitled to ration cards. The lamps and stoves used are old and inefficient, causing smoke and accidents. These problems are made worse because slum dwellers have to live in extremely small huts and tenements of between 90 and 180 square feet in size.

The number of family members at work among the slum-dwelling households in Bombay is quite high, and their income per head is close to the national average. But as they have to depend on the market for basic necessities and live in an unfavourable physical environment, they are kept firmly in a trap of poverty and disease. Over three-quarters of their monthly income is spent on food, and the rest goes on fuel, transport, and on doctors and medicines. The public distribution through ration shops does not meet their needs of food and fuel, and the very inadequate public health service pushes them into the hands of expensive and privately controlled curative services.

Inadequate Prevent Services

Preventive health services have remained rather poor in Bombay. A Municipal Health Department Scheme for establishing community health centres in the slums was not started until the mid -1980s. Again, this left out those living on pavements and in the inner-city chawls. The Extended Program of Immunization was not introduced until 1978, and the number of newly born children actually covered by this programme has remained low. Many parents have not protected their children by following through the full vaccination regimen. The existing Government and Municipal Health Institutions are mainly concerned with cure rather than prevention. While many of the slums are serviced with Municipal dispensaries, people continue to use private doctors and clinics, as the Municipal Dispensaries are too few to cope with the demand for their services.

Air-borne Diseases Become Prominent

The authorities concerned with the environmental and disease control have until recently paid more attention to the water and food-borne diseases, as these diarrhea diseases have been the major killers, especially of your children, in rural and urban areas. However, at least in the major and growing cities respiratory diseases are beginning to be an equally serious threat to life. In Bombay, for example, the mortality due to these respiratory diseases has increased faster than that due to the diarrhea diseases. In the recent past the death rate from tuberculosis was growing faster than the rate of growth of population itself. Many industrial factories and workshops add to the pollution while manufacturing their products, and when distributing them in road vehicles. Some of the items that they manufacture also themselves add to the pollution, like diesel or petrol engines. It is not only the population that lives where those industries are located that are the victims of air pollution : for the air currents stuck the pollution over to other areas of the city as well. In Bombay there has been much talk about industrial pollution especially inthe Chambur-Trombay area. In actual fact, however, the figures show that central areas of the inner city, like Lalbaug, Parel and Byculla are more highly polluted. This may be because the air currents from the land at the night push the polluted air from Chembur forward towards the sea in the west. Nevertheless, there have been reports not long ago of gas leakages in Chembur that show how dangerous this particular locality can be.

Poverty And Tuberculosis

It is true that no social group escapes from air pollution. But poverty, which forces people to eat in adequate and poor quality food, to live in congested dwellings, and to use smoky fuels, makes people’s condition worse, causing those who have fallen sick to die. In this way poverty makes people who have fallen sick from respiratory or diarrhoeal disease more likely to die. Tuberculosis, which is the one disease that causes the most deaths in Bombay, is related to poverty, and worsened by a dirty atmosphere at work or in the street or at home. By examining the figures for deaths from tuberculosis in the different parts of the city, it is found that the poor in the inner city due in greater numbers from tuberculosis than the poor in the suburbs or extended suburbs. One reason for this is that the inner city population contains a greater number of men over the age of forty, which is when the disease is most likely to cause death. Many of the jobs in the inner city are done by men, and there is a tradition of textile workers especially and porters ( mathadis ) living in male dormitories in the chawls. This explains some of the reasons for the large number of deaths from TB in these wards of the city. IN addition, the excessive consumption of alcohol, which causes an increase in malnutrition through lowered intake of food, may lead to TB. Also, the population density in the inner city is three to four times higher than in the suburbs or extended suburbs which makes it easier to pass on this infectious diseases, and increase its incidence.

Other Chest Diseases And Heart Ailments

Another important group of respiratory diseases consists of bronchitis and asthma, the second most important cause of deaths in Bombay from respiratory disease, after tuberculosis. These are closely associated with the wider environment, ( for example, the air pollution every where ), and the environment close by ( for example, the nature of people’s shelter and their contact with infection ). Both these diseases along with rheumatic heart disease ( which originates in untreated infection in the respiratory tract ) take their toll of life only from about the age of forty onwards. But repeated exposure to infection in childhood accompanied by lack of or inadequate treatment, may increase the likelihood of a chronic condition in adult life. The chest and heart diseases can affect each other. They are found to be a major cause of death in the same parts of the city, and are both likely to be made worse through air pollution. For the poor there are additional reasons why people may suffer from both these diseases at the same time : the strain on the lungs and chest due to manual labour, and the consumption of poor quality alcohol and unprocessed tobacco for example. All the chest and heart diseases are found to be more serious in the inner city, than in the suburbs, but especially TB.

Curative Medicines

There are, however, areas within the suburbs where mortality from diarrhoea, particularly affecting infants and children, is exceptionally high ; for example in the vast hutment areas from Chembur to Mankhurd. There have not been any significant and large scale sanity measures taken by the Government or Municipality in the localities where the poor in Bombay live, to prevent the contamination of food and water. Therefore, the decline in the mortality caused by diarrhoeal diseases must be due to curative drugs, which the poor have been observed to use very readily, and which the private medical stores and private doctors have come up everywhere to provide. However, there are limits to the success of curative drug treatment, and the risks of relying on these drugs without adequate knowledge should be stressed.

The Tasks Ahead

It is clear that the attempts to improve health in Bombay must pay far greater attention that before to the diseases that afflict the lungs and chest. This dies not mean that the fight against the contamination of food and water may be neglected. For this problem still remains with us. IN addition, it must be mentioned that accidents continue to cause many deaths in Bombay. These include industrial accidents, and accidents in the crowded homes of hutment dwellers, where women in particular suffer serious burns from stoves.

It is a complicated matter to control disease. The difficulties of prevention and cure have to be approached in many different ways. Various people from different social groups have to come together to attempt the task, but those most directly exposed to the diseases have the most important part to play. The stories in the earlier section of this book try to make the complexities more understandable and manageable, and try to show the parts different people can play in helping to bring about a healthier city, especially, of course, those people who are themselves most likely to be the victims of disease.

Community Action In Self Help

It is not Nirmala breaking her chappal and cursing angrily for having to clean up the slime on her feet which is important in the story. What is important is for people to understand how disease travels from infected faces to the mouth ( when we take in contaminated food and water ), and for people to be encouraged to do something to improve their local environment. There may not be a Pushpa in every locality to take voluntary action to organise its inhabitants to keep their environment clean, but it is very important that people get to know that garbage and filth in the neighbourhood threatens them directly in their homes through water, flies, and the dirt on their own hands and feet. The convenience of going to the doctor for a cure must not stop people from taking social action to prevent the need for a cure. It may be difficult to organise a community , but if you do not, you will pay the price of sickness and disease and the high cost of medicines. There is always a Sunita or Mumtaz who need to be told that cutting and cleaning the finger nails of the children is a cheaper option to visiting the doctor. The need for preventive action outside the home, ( using garbage bins, keeping toilets clean, keeping drains clear) is as important as preventive action inside the home ( washing hands and feet thoroughly, washing vegetables , keeping food and water pots covered. ) The household may notbe able to buy a plastic bin for garbage but an old tin can with a lid will do as well. The Municipality is responsible for supplying garbage bins, water and light bulbs in the toilets ( these are even more important than building flyovers and mending holes in the road). There should be no hesitation in demanding these facilities in slums colonies.

Govind’s story is like that of many who are under-nourished, live in overcrowded dwellings, and work in environments where the air is thick with dust, smoke, and chemicals. TB is a disease of both poverty and congestion ( an air-borne infection that is worsened by low levels of nutrition ), and it spreads among those who share the same living conditions. Some like Karim may make the problem worse by addition to poor quality alcohol and tobacco. But Govind’s family react to his disease by thinking of action they can take, like demanding more and better quality food -grins through the ration shops.

Ramesh’s case is another example of the same problem. It tells how the industrial polluters escape their responsibility by finding ways to get around the law. The result is that damage is done to the lives of workers like Ramesh. The experience of Bahadur shows that health is a political matter. He is a newcomer to the city, and he quarrels with a friend who is from among the managers of the factory. This forces him into new friendships and alliances. The Social Education Society mentioned in this story may not exist in most localities but the story is intended to stress the need for voluntary activity of this kind.

It is not only some big industrial establishments that pollute the air. Smaller workshops in slum localities like the one where Rita worked in Kurla have a no less damaging effect on people’s health. She knew there was no relief from the dreadful cough that she and many others in the locality suffered from unless the area was kept clean. The first step that she and Pinto took was to organise action to keep their garbage in proper bins rather than throwing it into the nullah. In this way they placed themselves in a stronger position to demand clean working conditions in the workshops that made soap. All this led them to look for knowledge about the environmental conditions existing in other parts of Bombay, and to understand the impact of air pollution on chest and lung diseases. In the process they understand the complexities of the situation that affects their health.

Understanding Disease, Doctors And Medicines

In an environment where treatment with drugs is in practice the main way of attacking disease, some knowledge about commonly used drugs, about drug treatment that takes a long time, and about the medical services, is most important. This is because if people take their course of medicines in too small a quantity , or at irregular intervals, or in too great a quantity, they man endanger the health of themselves, their families, and the community even more.

There are many like Fatima and Kamala, who rush to doctors whenever their children come down with fever, following a cold or cough infection. At times this treatment is at the cost of other necessities. Colds and coughs are very common in Bombay as the air is contaminated by smoke and dust from the factories, and fumes from cars, buses, trucks and autorickshaws. The fever which comes with these colds is not in itself a problem. It is a signal that the body is fighting the germs which have entered it. Most coughs and colds go away without treatment, and can be best coped with by staying healthy and well nourished rather than rushing to the doctor. In Bombay, however, where young children, particularly, tend to be repeated afflicted by colds, sore throats and coughs, it is important to keep a record of every episode. Colds, sore throats and coughs which come frequently and are accompanied by fever each time must be attended to seriously and medical advice sought because if untreated they can lead to major diseases like asthma and rheumatic heart diseases.

Doctors are very valuable in society for combating disease, but they are also subject to social forces. For example, the drug companies encourage them to prescribe a large number of drugs ; and patients, who feel that drugs are some sort of miracle, encourage them as well. In this sense, persons like Jamila and her husband have an important part to play by explaining the reasons for colds and coughs in the city, and helping people to cope with minor ailments themselves and to resort to cure in an informed way to save on costs along with ensuring appropriate treatment. The drug companies, too, should act responsibly so that people like Fatima and her family are not confused by an unnecessary number of different varieties of drugs. Finally, it is important to remember that a trip to a doctor takes time and costs money ; therefore, the patient and her family must not give up their right to ask questions about the disease or the prescribed medicine even if the doctor appears very busy ( or if important -looking people from the drug companies, whom Fatima noticed, are clamouring for the doctor’s attention.)

While Kamala need not have panicked about her child developing fever following a viral infection, and could have saved the expenditure on curative medicines ( drugs ), Seema absolutely had to cope with every difficulty to get to a dispensary so as to have the preventive medicines ( vaccinations ) given to her child. The DPT and Polio vaccinations which protect children from diptheria, whooping cough, tetanus, and polio have to follow a fixed schedule.

There are many difficulties to be faced by those poor families seeking this protection for their children. While Seema had a problem in finding the place where these vaccinations were given, many persons in the locality were not even aware of the need for such vaccinations. Persons like Kadam and Sakhu, who had carefully followed the course of vaccinations for their child, are very important people in the community. What is needed is for such persons to recognise the part they must play in the community. Stories like this one will perhaps will encourage them to do so. Kadam and Sakhu will do well to give out correct knowledge about vaccination courses, also to insist the people to take all their doses of medicines exactly as prescribed. But it is catastrophes ; like the demolition of hutments where Seema, Kadam and Sakhu lived, which cause greater problems in the proper administration of vaccinations. For then people lose most of their belongings, one of which might be the card giving the vaccinations for the child.

So it is also of great importance to call for a humane approach when dealing with slum colonies and re-settlement programmes when they are really necessary.

The early symptoms of disease must be recognised. A common virus ( cold or cough ) can be fought with little or no help from doctors or medicines. But there are other diseases which could become fatal if medical treatment is not sought. As Arunachalam explained, typhoid took Hema’s life at a young age due to lock of proper medical treatment. It will not help at all if medicines are taken in an erratic manner. There is a very definite dose and routine which has to be followed if medicine is going to provide cure. A feeling of relief after you first start taking the medicines does not mean that the disease is already conquered, as Lakshmi’s daughter-in-law thought. There can be a real problem, however, in meeting the cost of medicines which are often prescribed in large numbers and in many varieties. It might be worth finding out ( as Radha did with Arunachalam’s help) if it is possible to reduce the cost without weakening the treatment ( by avoiding sedatives and fever tablets for example).

There is nothing wrong in telling the doctor that you have a problem in meeting the costs. The doctor may be able to make up a cheaper course of medicines without making the treatment less effective. Stronger and more costly drugs are not always the best to take as many of them have unpleasant side-effects. There are a number of cheaper drugs that can combat the disease just as well if it is treated early.

It is very important to go through the period of rest (convalescence) as advised by the doctor and not to rush like Ramu did to his cycle-repairing workshop without fully recovering from typhoid.

Information about the arrival of the epidemics must be spread quickly, and persons like Arunachalama, ( the retired school teacher ) must realise how important the information that have is, so that it can be used well in advance to save the lives of people like Hema.

Harishankar’s story makes the point that all those living in the same type of environment run a high risk of coming down with the most dreaded diseases. Modern medicines, however, have made it possible to fight them. It is necessary for people to understand, and not fear these diseases; they should learn about the course of treatment that is possible, and about ways of making sure that the cure is successful , rather than behave scornfully as Harishankar did to Ramsahai. Diseases such as tuberculosis and leprosy need to be treated immediately. If treatment is delayed, risk to the person having the disease is great, and his ( or her ) infection will threaten the health of others in the family and in the community. Governmental agencies and various charitable organisations have taken action for detecting and treating these diseases. They have helped in spreading knowledge of the diseases, and they give treatment nearly free of cost. Local community groups can help these organisations and agencies to do their work well.

Treatment of tuberculosis or leprosy is spread over a long time period, and for the cure to be complete medicines have to be taken regularly and in the correct doses for the whole period. It is for this reason that the treatment consists of several drugs. If a person takes the medicines irregularly, the body begins to resist one or more of these drugs. It is important to know about the medicines being taken, and also to tell the doctor if one is suffering from some other sickness at the same time.

Access To Medicine Facilities

Access to curative services is very important for combating disease. But doctors are not always at hand and in the situation faced by Sushma some knowledge of what a person can do to save a life is very valuable. When her child came down with repeated loose motions, and the doctor could not be found for some time, her neighbor Smita’s knowledge about a home cure ( called Oral Dehydration Solution ) saved the child. This was because Smita had taken the trouble to attend the classes organised by the Mahila Mandal to teach such simple ways of coping with emergencies.

Although municipal services are less costly, people are often forced to go to private doctors because the municipal dispensaries are too crowded, and the doctors sometimes behave in an unfriendly way. Although a person like Rohit could not afford to pay the fees charged by the private doctor, his wife Roopa would take her child only to him. She was used to receiving special attention at her native-place as her relation was a compounder in a primary health care centre, and she found the municipal dispensary in the city most unwelcoming. It was necessary for Anupama to help Rohit and Roopa overcome their fear of visiting the municipal dispensary and save themselves from debt. One may not find an Anupama in every community, and everyone may not attend Balwadis as Anupama and Roopa did. However, the story points out what is possible in the right direction.

Prospects For Protecting Public Health In Bombay

The combination of air pollution, insanity conditions around homes and work places, and low nutrition, which is contributing to death and debility among those living on pavements, in inner city tenements ( chawls) and hutments in the suburbs and extended suburbs, has to be dealt with in two ways. Firstly, these groups must equip themselves with greater knowledge about their immediate physical environment and the diseases that threaten them most directly. Intellectuals, health professionals, voluntary agencies and the local administration , along with conscious and active persons from among the poor themselves, like the ones mentioned in these stores, are all very important people for building up the required knowledge, attitudes and practices. Secondly, these groups must press for sanitary reforms and real pollution control measures. The political strength of the slum dwellers in Bombay is well known as they total one-half the population of Bombay, and are a most important vote bank for the city politicians. Parties contending for political power within the city have begun competing with each other to stop any measures for slum demolitions and dislocations. Moreover, the vacant plots in slum areas have now begin attracting private builders, resulting in the cheek by jowl existence of slums and middle class housing. Many members of the middle class find these houses acceptable as the sky-rocketing prices of housing have made similar apartments in environmentally safer localities too costly for them. The political importance of the slum dwellers and the self-interest of the middle class living in their midst are the two most important facts that will help bring about sanitary reforms and real pollution control measures.

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