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‘Toilets can be Temples’

Indians have to accept that sanitation is not a dirty word.

From the Economic and Political Weekly, Oct 20,2012

What a lot of fuss about a remark that is at worst a predictable alliteration and at best an attempt to provoke a discussion on something we hate to talk about – sanitation. Union Minister for Rural Development Jairam Ramesh, who is not averse to hogging media attention, chose to launch the Nirmal Bharat Yatra against open defecation by making the deliberately provocative statement that India had more temples than toilets. As he had hoped, his remark has triggered a discussion. However, the discussion has not been on the pitiful lack of toilets but on religion.

The Bharatiya Janata Party spokesperson decided that Jairam Ramesh’s remark “hurt the fine fabric of faith and religion” – forgetting that the “fi ne fabric” of human dignity is hurt each day as almost half the population of this country is forced to defecate in the open. And the Congress Party, instead of reiterating its commitment to an urgent need like sanitation, chose to tie itself up in knots, as it has been doing lately, by talking about how it respects “the sanctity of every religious place irrespective of the community it belongs to”.

In this pointless exchange of words, both parties missed a chance of demonstrating their understanding and commitment to the concerns of the aam aadmi and aurat. In fact, Jairam Ramesh has to be commended for emphasising that sanitation has an important gender dimension and that it is women and girls who suffer most the consequences of a toilet-less existence. One cannot recall another senior government functionary in recent times repeatedly reiterating this important aspect of sanitation.

If the public space for debate had not been so dominated by the corruption scandals being unearthed each day, sanitation might well have become the talking point. Around the same time as Ramesh launched the Nirmal Bharat Yatra from Sevagram, Wardha, which will end in November at Bettiah in West Champaran, Bihar, the Supreme Court directed all states to ensure that within six months every school had separate toilets for girls. This is after it had already given similar directions last year but which many states had failed to implement. The record of most states on this question of separate functioning – the key word being “functioning” – toilets for
girls is dismal. Only 44% of schools that come under the Right to Education (RTE) have separate toilets for girls. This is the
national average but the performance of individual states on this count is shockingly poor: Chhattisgarh, 20%; Jammu and
Kashmir, 22%; Madhya Pradesh, 23% and Bihar, 27%.

The lack of toilets is not the only reason girls drop out of school between the ages of 11 and 14, but it is an important one. In their absence, young adolescent girls have to risk going out into the open fields during the day, or run all the way to their homes. Other factors also contribute to girls dropping out – the distance of the school from their homes, the lack of public transport, their burden of household chores and looking after siblings, the lack of female teachers, the absence of safety during the journey to school even if there is transport, and early marriage. Yet the absence of  toilets is an easier problem to fix than some of the others and could start making a dent in the high dropout rate of girls from schools.

On the larger question of sanitation, there are few who will deny that this issue takes on a peculiar twist in the Indian context. While personal cleanliness is raised to the level of a religious rite, there is little concern about dirt and filth in public spaces. As a society we continue to accept that some people are born to clean the dirt so that others can avoid thinking about it. Why, for instance, despite the ban on manual scavenging in 1993, do lakhs of dalits, the majority of them women, still do the daily and inhuman task of removing human faeces from the estimated 26 lakh dry toilets in different parts of India? And why does this not raise enough of a stink?

Typically, instead of implementing the existing law, the government has now tabled a new law in Parliament that includes those who clean sewers and septic tanks. Are we to believe that a new law will end this shameful practice if nothing has happened to abolish it, 65 years after Independence? Ultimately, if we are to end manual scavenging it is the casteist mindset that has to be abolished. You can have programmes to end open defecation, or give subsidies to build individual toilets, or offer panchayats incentives to construct
community and public toilets. But things will change only when Indians decide sanitation is not a dirty word; that no one group of people is destined to clean up after other people; that toilets can be the temples of a modern, just and democratic country.



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Medical Emergency of the Urban Poor

by Kalpana Sharma

Explores the impact of poor urban planning on health

A man who works as a driver in Mumbai discovered recently that his wife, who complained of breathlessness, had a heart problem. She has a blocked artery and a faulty heart valve. Like others of his ilk, this man lives in a slum. His salary as a driver is not enough to rent, leave alone buy an apartment anywhere in Mumbai.  So he lives in a “regularized” slum, which cannot be demolished, and which is, ironically, located on the most expensive real estate in Mumbai, in the upscale neighbourhood of Malabar Hill.

This preferred location, however, makes little difference to him when facing a health crisis such as this. The choices before him are stark. If he does nothing, because he cannot afford to get his wife treated, then she will die. If he chooses to get her treated, then he faces lifelong indebtedness.

In a city with some of the most expensive and modern health care facilities, millions of lower income and poor people face the dilemma facing this driver. As opposed to their rural counterparts, even poor people living in cities are well aware of the medical interventions that are possible to prolong life and to deal with life-threatening conditions. But they also know that such interventions are out of their reach in an increasingly privatized health care market. The public health care systems that exist are simply not enough to meet the demand even for ordinary health conditions leave alone for specialized care.

Mumbai is actually better served than most other Indian cities with public health facilities. The Brihanmumbai Municipal Corporation (BMC) runs four teaching hospitals, five specialized hospitals, 16 peripheral hospitals, 28 maternity homes and several hundred dispensaries and health outposts. Out of the estimated 40,000 hospital beds available in Mumbai, around a quarter come under the BMC. In addition the state government runs one medical college, three general hospitals and two health units with a total of 2,871 beds. The Central government also runs one hospital.

Yet, despite the availability of these services, people who cannot afford to spend on private health care still do not necessarily see public services as the first choice. Several studies have shown that as many as 77% . in urban areas and 63%. in rural areas turn to private practitioners for outpatient care because the public facilities are either too far, or their procedures are too bureaucratic and take too long to access. Even amongst poor people who cannot afford private care, the percentage of those who use it is over 60%.

However, for in-patient care, the poor seek out public facilities, even if they are at some distance from where they live, because they are the only ones that are affordable. However, it is evident that these are inadequate to meet the demand. The overcrowding seen in every public hospital is a stark reminder of the shortage of affordable beds in a city where the majority of people cannot afford expensive health care. Furthermore, the big hospitals in Mumbai serve as referrals for people from across the state and other states.

Access to health care, however, is only one part of the larger story of health status of the urban poor, one of several hidden developmental crises. Compared to their rural counterparts, poor people living in cities should be better  off. There are many more hospitals, many more doctors, running water that is reasonably potable, sanitation that is passable, electricity and public transport. Even the poorest can earn something in a city like Mumbai.

What is forgotten is that even if they do not suffer income poverty to the extent that people do in rural areas, the urban poor face other forms. of deprivation that have a direct impact on their health. As most of the urban poor live in congested localities, often in flood prone areas, they are the first to succumb to water-borne diseases like typhoid and gastroenteritis. Every monsoon, the first cases of vector borne diseases like malaria and dengue are almost always reported from slum areas. Crowding and living in poorly ventilated dwellings also ensures the spread of communicable disease like tuberculosis. According to the latest data from the National Family Health Survey (NFHS-3), the prevalence of medically treated TB is much higher in Mumbai than in urban Maharashtra (590 vs. 367 per 100,000). Also, predictably, within Mumbai, it is much higher among slum-dwellers than non-slum dwellers (690 vs. 458 per 100,000).

The most telling comment on the health status of the urban poor is the nutritional status of children born and brought up in poor settlements. NFHS-3 has come up with disturbing data on the levels of malnutrition and under-nutrition amongst urban children. This data is indicative not just of levels of poverty, where families cannot afford to feed their children, but the prevalence of diseases, including repeated bouts of diarrhoea, which render children weak and unable to absorb even the little nutrition they do receive.

NFHS-3 shows that there is chronic undernourishment in 42%.of children in urban areas in Maharashtra, a state that is wealthier than India as a whole according to the wealth index used in NFHS. The survey found that 29%.of children in urban areas in Maharashtra are stunted (too short for their age), an indication of undernourishment over a period of time, 11%.are wasted (too thin for their height) indicating inadequate food intake or a recent illness and 21% are underweight, signs of chronic and acute under-nutrition.

In the context of Maharashtra, Mumbai is important for a number of reasons. 29% of the urban population of Maharashtra lives in Mumbai, the wealthiest city in the state. Yet according to NFHS-3, the nutritional status of children under five years in Mumbai was slightly worse than in urban Maharashtra as a whole. The survey also found that the nutrition status of children under five living in slums was substantially worse than those living in non-slum areas. For instance, while 47 %. of children living in slums were stunted, the percentage in non-slum areas was 42%. Similarly while 36%.of children in slums were underweight, 26%.of their counterparts in non-slum areas were the same.

What is happening to the urban poor is a story not just of income poverty but many other forms of deprivation. People come to cities in search of a better future. But the absence of living. conditions that are conducive to healthy living is actually rendering these people worse off than if they had stayed behind in their villages.

Kalpana Sharma is a Mumbai-based independent journalist and columnist. This is an extract from an earlier piece published in the Mumbai Reader 2008.