|Priorities in Health and Nutrition of the Urban Poor: The Case of the Calcutta Slums (CRED, 1991, 18 p.)|
Debarati GUHA SAPIR
«The slum: 400 baht a month for a family consisting of one father, one mother, eight children, four dogs, ten cats, six ducks and ten million mosquitoes.»
(Morell and Morell, Bangkok, 1972)
In the last decade before the end of this century, urban populations are projected to increase by 66% throughout the world, and by 100% in tropical and sub-tropical countries. The three major Indian cities of New Delhi, Bombay and Calcutta are all included in the list of the worlds 16 fastest growing cities, with growth rates over the last two decades of 125%, 88% and 75%, respectively (Harpham, 1988). Between 1971 and 1980, Indias urban population increased by 46,4%, resulting in a total urban population of approximately 160 million in 1981. Today, about a quarter of Indias population is urban and by the end of the century urban populations will account for 33% of the total or 230 million (Hardoy and Sattherwaite, 1989). The growth in these cities has been largely in the lower socioeconomic classes. Scattered evidence suggests that birth rates among the urban poor in all three of these cities are high and that this may even be a greater net contributor to their increase today than rural urban migration.
Aggregated statistics of urban populations are almost consistently better than the rural statistics. Although commonly used, aggregated statistics are extremely misleading and provide a false sense of security. Available evidence suggests that developmental indicator rates of the urban poor are vastly different from the aggregated figures of urban populations overall (Linn, 1983). Basta (1977) presents a series of illuminating examples of the differences in rates of development indicators between the urban poor and the urban rich. In many cases, the rates were worse than national averages and in some cases, worse than the rural levels. The range of differences of disease specific prevalence rates for the urban poor were often two or three times worse in comparison to the rural poor. For example, Basta observed in Manila rates of gastroenteritis among squatters to be 1,352/100,000 compared to rates of 780/100,000 among the non-squatter population. Similarly, in Bombay, leprosy in squatter settlements was 22 per 1,000 compared to 6.9 per 1,000 for the city as a whole (Ganapati, 1983). The overall urban literacy rate in India was 57.4%, according to the 1980 Census, but was only 26% among the urban poor, according to a Task Force Report on Housing and Urban Development (Government of India, 1988). Unfortunately, systematic statistics on the urban poor are difficult to obtain for at least two reasons: the data are almost always consolidated over the entire urban population; and evidence of the differences between urban poor and rich is scattered and fragmented (Boyden, 1991).
National Plans for Urban Health
Urbanisation measures in India to manage massive influxes and high birth rates have been seriously inadequate. The consequence has been a proliferation of some of the worst slums in the world in Calcutta and Bombay. Decennial growth rates in these cities have been 37.8 and 30.4 respectively (Government of India Census, 1981). Although large scale evictions have been reported in these Indian cities since 1980 (Srivastav, 1982), nevertheless, the urban growth rates of these cities show no significant signs of abating. As urban growth rates continue to increase, the problems as a result of high growth rates can only be expected to exacerbate conditions in the decade to come.
The national planning process, directed by the consecutive Five-Year Plans, significantly affects urban conditions and health programmes. However, neither the Fifth nor the Sixth Five-Year Plan (covering the periods 1975 to 1980 and 1980 to 1985, respectively) directly addressed urban poverty issues, although the Sixth Plan did allocate resources for «61,000» urban poor for «additional consumption benefits» (Government of India, 1988). The Seventh Five-Year Plan (1985 to 1990) represents the first attempt to address urban poverty issues directly. It places considerable emphasis on the improvement of slum dwellers living conditions and acknowledges the «growing incidence of poverty in urban areas» and the rapid growth of slums. Among other components of its strategy, the Plan proposes to improve the access of urban poor to basic amenities such as education, health care, sanitation, and safe drinking water.
Context of Life in Indian Slums
The physical, economic, and environmental conditions of slum populations in India can be quite different from those in rural villages. The most visible characteristic in Indian slums is the extreme penury of space. A survey conducted by the Delhi Development Authority in 1986 estimated that a typical family of four in the slums of Delhi, lived in a space of approximately 7.5 square meters. A report of the Government of India in 1988 reported that more than 67% of Calcuttas total urban population lived in one-roomed housing. In addition to lack of space, life is characterised by hard labour for all family members, including children, in difficult and life-threatening conditions such as construction sites or industrial sites where exposure to motorised traffic and open machinery is common. Reported child labour accounted for about 4,3% of employed males and 7% of working females among the urban population of India (Government of India, 1988; UNICEF, 1991). Industrial, automobile and human pollution of all types also aggravate the situation. Finally, social disruption due to increased consumption of hallucinatory drugs and alcohol, the power struggles among rival gangs, and the breakdown of the family structure, significantly reduce the quality of life of the poor.
This paper is based on data from a household survey of 2,603 families with at least one child under five years of age living in 37 randomly selected slums recognised by the Calcutta Metropolitan Development Authorities. In addition to standard demographic and socio-economic histories of the family, the survey obtained detailed information on health care use, maternal histories, dietary intakes of mother and youngest child, reported mortality and morbidity histories, and nutritional anthropometry. This paper discusses only a few of the issues addressed by the whole survey. Following this first introductory section, section two describes the history and context of the Calcutta slums, and the public services and administrative infrastructures that exist to support it. Section three presents the results of the survey, followed by a discussion of the results in section four. Section five presents the conclusions of the paper and the recommendations for priority areas for strategy development.
History and Context of the Calcutta Slums
The population in the Calcutta Metropolitan area had increased from 2.25 million inhabitants in 1921 to 10.2 million in 1981, with most of the increase occurring during the post World War II period. Since the partition of the country in 1947, Calcutta has suffered both economically and politically. During the Partition, a large number of refugees from East Bengal 1 (approximately one million) settled in and around Calcutta. Following the Bangladesh war in 1974, renewed waves of refugees (also in the millions) crossed the border and arrived in Calcutta with the eternal hope of making a living in the city. As a result, illegal squatter settlements developed in most of the available space in the city, including the embankments of railway tracks, bridges, and even on sidewalks. In Eastern India, Calcutta is the largest urban agglomeration. It was the major port and industrial area, which served an enormous hinterland covering much of Eastern India, until the early 1970s. Since then, the economic growth of the city has slowed down and along with it, its attraction to migrants has diminished. Although precise estimates do not exist, migration from neighboring states was certainly one of the notable factors for growth of population in the city. It is not longer the main source of growth today (Roy, 1983; United Nations, 1985; and Row, 1974). In fact, United Nations projections for the population of Calcutta for the year 2000 have decreased from 19.5 million in 1973 to 16.5 in 1985 (Hardoy and Sattherwaite, 1989).
1 Subsequently, East Pakistan, currently Bangladesh.
A wide range of estimates are cited for slum populations. Werlin (1987) reported the slums consists of 2.8 million, or a third of the 8.3 million registered inhabitants in Calcutta Municipal area. Harpham et al. (1988) estimate that there are 5.6 million slum inhabitants, or nearly half Calcuttas population. The Calcutta Metropolitan Development Authority (CMDA) report in 1983 stated that the slum population for the year 1981 was 3.02 million in the CMDA area. More recently, a report by the India National Commission on Urbanisation (1988) stated that 35% of Calcuttas population is living in «identified slums but it is estimated that all slums and squatter settlements are much higher». Based on a handbook of the National Building Organisation (1982-83), 67% of the households in Calcutta live in one room units, without private toilet or separate cooking facilities.
Estimates of the slum population of Calcutta vary greatly according to the authority addressed. It is not clear whether any of the estimates include the sizable number of unregistered poor, such as the itinerant pavement dwellers and illegal squatters. No matter which figure approaches the truth, the gigantic size of any estimate of the slum/squatter population in Calcutta is reason enough to warrant urgent attention.
Administrative Context and Efforts
The CMDA area is divided by the Calcutta Corporation into 141 wards (administrative units) and all wards have substancial slums or pavement dweller populations. The density of population in the overall CMDA area is 7,822 persons per sq. km. and the inner city of Calcutta was as highly populated as 31,779 persons per sq. km. as early as the mid-seventies (Bose, 1974).
CMDA classifies its slums into categories that are «recognised» and «unrecognised». The former are those which are officially recognised by the local self-government and therefore the urban authorities. Consisting of pavement dwellers and squatter colonies which are nearly equal or even larger than recognised slums, the unrecognised slums are treated, in an impressive flight of imagination, as nonexistent despite their tremendous size. The rationale for this policy seems to be to discourage these and other squatters from remaining in, or migrating to, the city. The hope is that without benefits, these groups will leave the city. The CMDA and the municipalities will not assist pavement dwellers or squatters because they do not want to give legal status to these two categories of the urban poor 2.
2 These nonexistent persons usually consists of the ultra-poor such abandoned wives, old labourers, handicaped persons, beggars and rag pickers who have no source of income and no links with their families. The pavement dwellers eat barely one meal a day and have no fixed sleeping place at night. Health care, whether free or not, is a low priority to both squatters and pavement dwellers and effectively inaccessible. Many arc addicted to tobacco or to liquor as and when they can obtain them.
The «recognised slums» are divided into two classes: those where the development package has already been introduced and those where it is yet to be introduced. These are known as «covered» and «uncovered» slums. Thus, the urban poor may be divided into four broad categories: those in «covered» slums; those in uncovered slums; the pavement dwellers and the squatter population.
Unlike most other cities in India and elsewhere, no section of Calcutta city is completely free of a slum. Settlements of all sizes squeeze in between upper and middle class quarters and continue to spread into any unoccupied space as an amorphous and shapeless mass. Individual slums tend to be homogenous across linguistic and ethnic groups. Bengali-, Hindi-, Urdu- and Oriya-speaking people will typically cluster into a slum according to their spoken language. Nearly all the Urdu-speaking slums will be Muslim. Some Bengali-speaking slums may also be Muslim. The remaining Bengali, Hindi and Oriya slums will be predominantly Hindu.
Consolidated efforts for urban development started in Calcutta in 1971, when CMDA was established to implement urban development plans for a total population of 10.2 million. Its jurisdiction cut across local authorities and encompassed 3 municipal corporations, 31 municipalities, and 2 special status areas extending into 5 districts surrounding the Metro core.
In 1973, slum-upgrading became part of Calcuttas urban strategy through the CMDA as a result of an interest free loan from the World Bank totaling US$ 35 million. It may have also been motivated by the realization of the authorities that destruction or neglect of the slums could be politically hazardous. The first loan was followed by an additional 87 million dollars in 1977 and 147 million in 1983. The CMDA implemented the Bustee (slum) 3 Improvement Programme (BIP) and undertook infrastructural improvements such as installation of water supplies and latrines, and improvements of roads and lighting. Critics of the BIP have pointed out that purely physical upgrading has worsened the position of the bustee populations. Facilities, including drainage, have not been maintained and State funds have tended to be diverted towards salaries. Rent and water rates increased by 43% in the improved bustee areas compared to 16% in the unimproved ones (CMDA, 1983). This effectively meant that poorer tenants were forced to move out. Today, half of the bustees have received no benefit from the improvement programme. Informal sources cite an excess of funds couples with unplanned spending as one reason preventing sustained progress in this sector. In 1986, CMDA launched a health programme with the assistance of the World Bank but the health programme remained a very small part of the global urban development package. The overall package continued to focus on infrastructural rather than service development.
3 A slum or Bustee is defined by the CMDA as a plot of land not less than 7,200 sq. ft. of human habitation, occupied by huts or intended for the purpose of building huts. Thus all units living in smaller groups or on their own are not slum-dwellers and therefore do not fall within the purview of their programme. Between 1979 and 1980, there were approximately 2,000 bustees in the Calcutta Corporation Area. In the rest of the Calcutta Metropolitan Area (CMA), there were about 1,000 additional bustees.
Information was collected on a total of 14.999 persons and 2.603 families. The age distribution of both sexes were significantly in favour of young adults in their reproductive years. The distribution of religion by occupation groups is displayed. The predominant religion was Hindu accounting for 68% of the population, followed by Muslims accounting for about 30%. There were practically no other religious groups. Among the Hindus, over two-thirds were of low castes or tribes. The average family size was 5.8 with a crude birth rate of 55.3 per 1,000 population. Occupations varied among religions. Muslims were typically in wage labour or petty business whereas the Hindus were typically on salary. Overall, wage labour was the most frequent occupation, accounting for nearly one quarter of the total, most of the families cited economic reasons for moving to the city and 38.4% had moved within the last ten years. Income was very difficult to estimate, especially because the respondents were rarely able to vouch for the husbands income. A rough estimate from the reported figures would place the majority of the families within a range of 400 to 800 rupees a month.
Over half of the families surveyed lived in temporary or semi-temporary shelters. The housing consisted either of improvised roofs with one or more anchored walls or entirely improvised structures. The majority of the families (79.6%) lived in spaces with one or more anchored walls which had a thatched or unattached roof. Over half of the families (55.1%) lived in one room and 60.2% cooked in their living/sleeping quarter. Among those who did not have separate kitchens, the majority used either kerosene or biomass fuels (both cheaper fuels), while coal and gas users generally had more than one room and separate kitchen areas. The average number of persons per room was 4.2. Almost all drinking water was drawn from public taps and the main source of light was electricity, principally drawn from illegally tapped lines.
Health Status and Health Services Use
Approximately 70% of the surveyed slums had a health centre or hospital in the vicinity, of which less than half were Integrated Child Development Centres (ICDS). Based on a CMDA report (1983), there were 163 general and specialised hospitals with 26,365 beds available in the Calcutta Metropolitan area. The total number of hospitals in the State of West Bengal in 1988 was 412. Nearly 40% of the hospitals in the State are within the Calcutta Metropolitan area. Thus there about 307 persons per bed in the city compared to 1,161 state wide (Statistical Handbook of India, 1991). It should be noted that the presence of these institutions does not reflect services actually provided or used.
The rates of immunisation were hogh, over 70% of children had at least one dose of an Expanded Program of Immunisation (EPI), with the exception of measles. Only 22% of the male children and 19% of the female children were vaccinated against measles. The majority (80%) of the immunisations were provided by government hospitals. Very few immunisation were administered through the primary health care (anganwadi) structure. The type of medical care used by the population varied among allopathic, homeopathic, ayurvedic, and other lesser known forms of traditional medicine. Allopathic services accounted for 70.2% of all those who were ill in the previous year. Of the remaining percentage, homeopathy was a significant alternative, representing 14.1% of the total. Non-allopathic forms of medicine were used more frequently by females than males. Average monthly health care expenditure for the family was a little over 60 rupees, of which nearly 80% was spent on medicines and tonics. These results correspond to findings from other studies. For example, the average monthly health care expenditure in Delhi was observed to be 40 rupees per household (Sinha and Ghosh, 1988). Data from the CMDA survey (1988) similarly indicates an expenditure proportion of nearly 90% of the health expenditure per episode for medicines. Gender differences were significant in patterns of health expenditures, where the proportion of females decreased as levels of expenditure per episode of illness increased.
Maternal and Nutritional Characteristics of Women
Table 3 presents general maternal and nutritional characteristics of married women included in the survey. The average age at marriage for females was 17 years compared with the national average of 18 years. More than 31% of the women were married before the age of 16 years and 20% of the first pregnancies occurred before 16 years. By the age of 20, nearly 75% of these women had been pregnant at least once. Childbirth occurred almost entirely at hospitals with nearly 80% in Government hospitals. Less than 10% were delivered at home or in non-institutional surroundings. Similar statistics were observed by Yosudesian in a study of Bombay slums (ORD, 1991).
The age-specific fertility rates ranged from 641 per 1,000 women 16 to 19 years of age, 400 for women 20 to 24 and 254 for women 25 to 29 years of age. The general fertility rate was 312 per 1,000 women 15 to 44 years of age and the total fertility rate (expected births per woman through her entire reproductive period) was 8.54. Although this last figure is an overestimation dur to the sampling design of the survey, it should be remembered that the majority of the slum women are young and this rate is probably fairly close to reality. Twelve per cent of the births occurred within 18 months of the previous delivery and 39% within 24 months. More than a third of the women had one child under one year of age and 7% were pregnant at the time of the survey.
Nutritional deficiencies were calculated for calorie, fat, and proteins. Distribution of observed calorie intake (adjusted for age, weight, and maternal status). Severe calorie deficiency was defined as intake < 2 standard deviations of the mean requirement for age, weight, and maternal status (assuming moderate activity). The calorie deficits were the highest in lactating women and among the younger age groups, particularly among women with one child under two years. Significant deficiencies were also observed in pregnant women. Fat deficiency was the second most prevalent condition. Both calorie and fat deficiencies increased with parity and family size indicating the vulnerability of this group to competing demands for food. Protein deficiencies were the least compared to calorie and fats. Among occupation groups, domestic servants displayed large nutricional deficiencies although the chisquare statistic was significant only for protein deficiency. Muslim women, women with higher parity, and women whose husbands worked as wage labourers all displayed significantly higher nutritional deficits (chisquare statistics of 7.7 and 7.03, respectively, significant at the p < 0.05 level). Odds ratios (OR) revealed higher risks for women with children under two years (OR = 5.11), for women in families with over four members (OR = 6.8) and for mothers working outside the home (OR =5.7).
The results presented in the preceding section raise various issues regarding risk factors and determinants of urban health and nutritional status.
Environment and Sanitation
Pollution from a variety of sources was possibly one of the most important health risk factor in the slum areas. The potential for indoor air pollution and associated risks is indicated by the number of the families who cooked and lived in the same room. Although exposure data were not collected in this study, it is well-known that the toxic constituents of kerosene and chemicals from the combustion of biomass fuel can cause acute respiratory infections (WHO, 1991). Its health impact on children and old persons who sleep and live in this area can be considered serious (Boyden, 1991). As expected, single roomed housing and use of biomass fuels were associated with poorer households.
Specific environmental risks and potential hazards associated with small scale economic activities in the slums were exceedingly high. Some examples, anecdotally observed by epidemiologists in the study team, indicated the high potential for occupational risks in many of these slum communities. For example, in the Biplabikhudirampally slum, several small factories produce sulfuric acid, the vapours of xhich engulf the slum all day. In Auxilium parish slum, the main slum «industry» is to recover and recycle metal from old car bodies which is then used to manufacture to telephone cables. At the final stage, the sifting process produces large quantities of fine metal dust which the workers continuously inhale. Another example was the Salt Lake slums, where the inhabitants principal occupation is the manufacture wooden ice cream spoons. The production process required the workers to dip the wood and bark by hand into heavily polluted water without any observable precautions or evidence of subsequent cleaning. Finally, street level habitation of the majority of the urban poor ensures the inhalation and continuous exposure to vehicle exhaust fumes known to be rich in carbon monoxide, oxides of nitrates, and transient suspended particulates, the human health effects of which have been widely studied (Hamza, 1989, WHO, 1991).
Piped water was generally available to most slum dwellers and would normally indicate safe water and consequently, lessened risk of water borne diseases. However, several studies have found substantially higher rates of child mortality associated with use of public water taps compared to yard connections. Victora et al. (1988) reported a 4.8 times higher likelihood of infant death from diarrhea in families using public taps compared to infants with in-house piped water. Similarly, Pickering (1985) estimated death rates in Gambia twice as high for children using public tap water compared to those having household connection. The weakness in these findings are clearly that they do not adequately control for economic status. This factor confounds the results by disguising the prevailing nutritional of status of the infant, a major determinant of the vulnerability to disease. In this study, while tap water was widely used, garbage dumps, sewage disposal, and industrial wastes were equally frequently located in and around the habitation areas and close to water sources, opening up possibilities of contamination, of the fetched water. Although adults generally defecated at the latrines provided in many slums by the Slum Improvement Programme, children were observed to defecate at any open drain or convenient sidewalk. They were largely left on their own by mothers who were at work or running errands. Supervision of children by older family members (such as may have been the case in rural areas) was rare.
Public sector health services at the community level is supposed to be delivered through the Integrated Child Development Service (ICDS) centres for preventive and nutritional services. It is the main provider of primary health care throughout the country and is supposed to be installed at community levels everywhere. Less than half the slums included in the entire study had an ICDS centre serving them. Although health centres and primary schools were available, their effectiveness was less than evident. Most public sector health centres either had their posts vacant for some time supplies were unavailable or inadequate. The hours of operation were limited and therefore, created significant barriers to their use by the target families, whose members generally worked during those hours. In terms of health care service utilisation, the ICDS centres were described as «highly ineffective» by a staff epidemiologist on a site visit and this opinion was generally shared by the employees of the centres themselves. Their lack of effectiveness could be explained in several ways. Specialised services by a physician or a nurse are provided in the clinics only once a week at best. The community health workers have limited health training and few drugs at their disposal. They are unmotivated due to low pay and have limited contact with their clients because they conduct relatively few house to house visits. Their training is oriented towards health education rather than the detection of health problems and, while this is not a shortcoming, it does not help to resolve existing health problems or to improve the utilisation of the centre.
The public sector health facilities in Calcutta seem largely used for emergency purposes. For all other care, private practitioners or pharmacists are used. A study by the Indian Council Medical Research (1985) reported that 85% of the people did not use the Maternal and Child Health (MCH) clinics in the area. They reported that lack of information and awareness of the services of the clinics was partially responsible for the low use. From this survey as well, it seemed that the residents had little encouragement or information as to how to best use the community facilities.
Finally, the traditional sector seemed to provide a substantial proportion of the health care. The 14% reported in this survey is probably an underestimate due to the low importance given to consultations of non-allopathic services. In the current climate of privatisation, financial sustainability, and competition, the existence and role of alternative medicine may be important to consider for manpower planning and for exploring ways of integrating them into the system in a more functional and beneficial manner.
The proportion of medical expenditures on drugs and pharmaceutical products was high in this survey. There is an excessive reliance of medicines, vitamins, and tonics, which were actively advertised and promoted in the study areas. More importantly, Greenhalgh (1987) has documented the significance of the frequent presence of physician-owned dispensaries or the common practice of pharmacists serving as medical consultants, dispending drugs according to the symptoms described by the client. All of these factors contribute to the elevated consumption levels of medicines and pharmaceutical products and make them the main element in health care expenditures.
This survey revealed two factors indicative of the implicit value of women in terms of her familys desire to invest in her health care. First, traditional medicine, which is generally cheaper and considered to be low status or less effective in urban communities, is used more frequently by women than by men. It conceivably represents the familys decisions to invest in a cheaper form of medicine for a cheaper form of life. Substantiating this, in a slightly different way, is an example from a cholera epidemic in a culturally similar community in Bangladesh. During this cholera epidemic in Bangladesh, women between 20 to 45 years of age had case fatality rates three times higher than men of the same age group. Investigation revealed that women tended to be taken to the hospital at later stages of illness than men, substantially reducing their chances of survival (Sapir, D.G., 1986). The second factor, that revealed the familys attitude towards medical care for women, was the pattern of health expenditure. Men accounted for increasingly larger proportions as the treatment costs per an episode of disease increased. Barring the possibility that men contract preferentially diseases that cost more to treat, it is clear that the households are not willing to buy the same expensive care for the women that it does for the men.
The rate of wasted pregnancies (abortions, stillborns, and miscarriages) was relatively high in this sample (87 per 1,000 live births). In addition, this figure may be underestimate because unrecognised miscarriages and more importantly, lapses in recall of these events, are well known sources of error. Two of the most important conditions for risk in pregnancies are those linked to early maternal age and nutritional deficiencies. In this survey, the majority of the women were pregnant at least once before the age of 19 and a significant proportion even earlier. The mean age of marriage was 17 years. Severe nutritional deficits were not only prevalent in all the women, but deficits were particularly high among the younger ones. All of these conditions jointly constitute a major determinant of pregnancy and maternal risk. These risk factors are also linked to low birth weight and slow growth velocities in infants, factors contributing to infant mortality (Kurz and Sapir, 1992). Rates as high 105.5 per 1,000 live births in India for infant mortality can be expected from women married between 15 and 17 years (Government of India, 1989). Although there ere only a few scattered studies on this issue for the urban poor over the world, a study by ICMR (1985) reported that the main causes of elevated infant mortality in the Delhi slums were due to prematurity which is linked to prenatal nutritional status and age of mother, as well as tetanus which is a vaccine preventable disease.
Most deliveries occurred in the hospitals. As a statistic this can be seriously misleading. In hospitals serving the urban poor, the conditions in which deliveries occur are barely acceptable, in terms of cleanliness, equipment, and quality of postnatal care. Hospital deliveries, in themselves, do not necessarily reflect modern or even better conditions. Among the women in this survey, it was interesting to observe that the main reason for going to the hospital was that any postnatal services or supplementary feeding would be provided only to children whose births that have taken place in hospitals or clinics. This survey did not address maternity issues within the confines of the hospital; however, the literature was examined to see whether some light could or thrown on the quality of care and profiles of use.
The existing data on maternal mortality is unreliable for a variety of reasons and unfortunately, there are few maternal mortality studies on urban poor (Royston & al., 1991). Of the few that exist, two studies of Calcuttas hospitals deserve mention as those serving nearly exclusively the urban poor communities. Studies by Dawn (1972) and Chowdhury (1976) estimated maternal mortality rates (MMR) at 950 per 100,000 live births at the Nilratan Sarkar Hospital. They reported hemorrhage and hypertensive disorders of pregnancy as the two most important direct causes of this mortality, with anaemia and hepatitis as the principal underlying causes. Similarly, Konar (1973) and Guha (1972) report MMR as high as 850 per 100,000 deliveries at the Eden Hospital. The authors pointed out that most of the maternal deaths were in the lower socioeconomic groups, occurring within 24 hours of admission and were linked to anaemia caused by parasitic diseases. Both anaemia and hepatitis are conditions that are particularly amenable to public health action and are relatively easy to control. Therefore, their presence as principal underlying causes of urban maternal mortality underline the weaknesses of the current public health care system.
The statistics on the extent of nutritional deficits in adult women overall and in particular, in pregnant and lactating women are scarce (Gross and Monteiro, 1989). In this survey, severe nutritional deficits for lactating women releaved that the increased needs of women during lactation remain unrecognised by the family. Pregnant women displayed significant deficits but at levels lower than those in lactating women. Pregnancies were recognised as a physical condition requiring food supplements; however, lactation was not. With regard to deficits in younger ages, this testifies to the age bias in Indian society where younger women command little respect or decision-making power within the family structure. Larger family sizes also increased the risk of nutritional deficits in mothers. Their total intake reduced significantly as family size increased, indicating that the absolute quantity of food available in the household probably remained the same, regardless of the increased size of the family, it would have been useful to examine whether the greater family sizes were due to more children or more adults, because the revenue potential or consumption patterns would change accordingly. All of these factors decrease the mothers nutrition and have serious implications for infant mortality and child survival. Efforts on improving the nutritional condition of women before and during child-bearing would be a cost-effective solution for reducing infant and child mortality.
The main findings of this paper pertain to maternal and nutritional aspects of urban poor women and health specificities of the urban environment. The study is based on the fact the urban populations form a substantial part of India and among them the poor are an increasing proportion. Their condition remains unrecognised as urban statistics are generally averaged over the entire urban population and thus misleading priorities in urban development. The survey confronted difficulties in estimates of the slum population, that varied enormously. The principal findings of the survey were the following: the significance of the traditional sector in health care; the high cost of medical care and the high proportion of medical expenditures spent on medicine, the severe caloric and fat deficits among younger women and lactating mother; the tendency to spend less for medical care for women; and the penury of space and consequential exposure to polluants (e.g. toxic fumes from biomass cooking fuels). In the analyses of these findings, several areas have been identified as practical priority issues that need to be addressed by policy makers.
The urban sector in most developing countries is the leading sector in generating national wealth, therefore as Ohta and Cassim (1987) point out, the urban sector can pay for improvements of itself. The affordability review of four metropolises conducted by Ohta and Cassim indicates the poorest 20% of Calcutta receives 7% of the income. Lea and Courtney (1988) estimated 60% of the city to be below absolute poverty levels. In general, poor health and poor economic conditions among large sections of a densely populated community such as the metropolitan centres of India represent many disadvantages to the community as a whole and therefore, it is in the interests of the community to provide for the poor. Public policy on health, nutrition, and social welfare in India has traditionally emphasized rural priorities and has only recently recognized the ongoing explosion in its principal cities. The specificities of the conditions surrounding the urban poor are important enough to warrant a fresh look at the urban health care delivery. Primary health care models, largely developed for rural populations, cannot simply be transposed to the burgeoning urban poor communities in different parts of the world. Health and nutritional programmes for the urban poor should be designed and implemented according to their needs and environmental content. In Calcutta, primary health care is severely underdeveloped. Almost all care to the slum populations is provided through hospitals and is, thus, entirely curative in nature. Because the whole primary health care concept was developed from rural area population standards, the structure and orientation of the system is clearly difficult to apply in urban settings without appropriate modifications. As a result, the scope of the programmes are limited and the services are available only to those who actively seek them.
A major weakness in this survey has been the exclusion of the ultra-poor and the homeless. The issue, nevertheless, demands mention here as an aspect that the study had to confront on a daily basis while in the field. The ultra-poor are unequivocally a priority group and not only because they are the most disfranchised of all groups but also because they constitute a significant proportion of the global urban poor population. Existing outside the administrative-legal structures, they are individuals whose place of sleep or night space changes daily 4. The lack of address prevents them from availing of any facilities including the use of hospitals provided by the Government for the poor or services such as «fair-price» ration shops. The pavement dwellers in Calcutta are a large and significant part of the its urban environment and play a very important role in the citys developmental and growth potential, not to speak of the more fundamental considerations of social equity and justice. Special programmes through a comprehensive package of shelter, health care, and economic support programmes are urgently needed for this group. Mobile health care vans for evening or night services for these poor can provide care effectively to a large proportion of the poor, who would be otherwise unable to obtain them.
4 See Sattherwaite and Hardoy (1989, see Chapter 3) for an illuminating discussion on insecurity of shelter, where Calcutta is cited as an extreme case. The «hot-bed» evidently, particular to this city, rents out beds by the hour for the homeless.
The neglect of the health conditions of pregnant mothers and of young women as precursors to conditions leading to maternal mortality also bears witness to the lack of serious efforts to improve health of women, even if it were just in the interests of the children they are to bear. The loss of a mother is possibly the greatest comprehensive disadvantage any child and family can have. Programmes targeting the prevalence of risk factors producing life-threatening conditions at delivery should be addressed urgently, starting with better studies on the extend of and the underlying causes of maternal mortality. Maternal care could be improved by a system of upgraded traditional midwives (under some from of supervision), which would not only resolve the overload on understaffed, underequipped hospitals but also lower costs and provide cleaner and effective services.
The effective use of health care by women in the Calcutta slums as in India is closely related to her status and value in society. Urbanisation has done little to change traditional attitudes and roles towards women among the urban poor. The findings concerning women in this study are an indictment of a society whose view of the woman is that of a disposable or a replaceable resource. The alarming rates of nutritional deficits among young women, the high rates of wasted pregnancies, the preferential use of traditional medicine, and the lower levels of health expenditure for them, all bear testimony to the poor condition of the ordinary, low-income urban woman.
Much has been written about oppression and marginalisation of women, less has been done to mitigate those circumstances. While there are admirable examples of action towards equal rights of women in the country, the rank and file, particularly in poorer states such as West Bengal, still live in oppressive conditions. Given the low social status and her weak decision-making capacity in her immediate family structure, special programmes for women only serve to marginalise her further, to isolate her needs and to set her apart. It was clear from the experience during this survey, that few of these women can afford either to be special or to fight for their rights within their day-to-day social and economic context. Policy makers must recognise that persons other than the targeted group of women (husbands, mothers-in-laws and elder relatives) make decisions and direct life-styles. Therefore, strategies aimed at improving the female condition could be directed more fruitfully at these realities, programmes for the betterment of the women risk remaining eternally project-oriented and voluntary sector action, vulnerable always to passing economic and social winds.
The epidemiological specificities and therefore, priorities in the health needs of urban populations are different and need to be clearly identified and considered for planning. For example, timings or hours of services need to be geared to women working long and fixed hours as construction labourers or domestic servants. Specific health risks such as traffic accidents, food poisonings, and tuberculosis are health problems that are more frequent than in rural communities and require different types of services. Efforts also are required for the rational use of drugs and unadapted prescribing practices that could partially counteract the negative aspects of pharmaceutical promotion among the urban poor and their reliance on drugs and vitamins as the main health care intervention. Indoor air pollution, particularly for mothers and children, is a major risk factor for acute respiratory illnesses.
An important strategy implication revealed in this study is the importance of misleading or falsifying statistics often used for programme development and analysis. Data on immunisation coverage without data on follow-up doses, estimation of available health care services without accounting for the traditional sector, use of health centres and posts as indicators of services without indicators of operation, are examples of how realities can be distorted and planning can become unfocused. The use of data on the existence of institutions without information on their actual effective use can and has served as alibis, providing satisfactory indications of progress while disguising the fact that nothing is actually being achieved. It should not be surprising to find that programmes do not work, if irrelevant or misleading indicators and data are collected and used. New and more imaginative approaches to the collection and use of indicators are essential to assess the situation realistically and promulgate effective policy. For exemple, wasted pregnancies along with maternal mortality are perhaps the two most revealing indicators of maternal health and status of child survival in a community. Unfortunately, neither have been recognised for their importance and data on both of these remain fragmentary and unreliable.
Finally, a major problem remains, effective access to health care services, although urban health services are extensive and for higher quality than those in rural areas, the problem is that access to these facilities even if they are free for the cities poor is difficult 5. In addition, the out-patients departments of hospitals are pressed to capacity and much beyond because only a few hospitals actually cater for poor, the homeless or the disfranchised. Outreach programmes to break through social barriers to use of available services should be incorporated in primary health care programmes. Hospitals should have outreach workers who are able to provide essential primary care on site and refer patients to the hospital serving the area.
5 At the seminar at which this paper was presented, a participant mentioned the several slum residents, living behind the prestigious All India Institute for Medical Sciences Hospital officially providing free/subsidied care to the general public, said they did not seek care there.
By the end of the century, half of the worlds population will live in cities. Calcutta and other Indian cities will remain among the top of the list of the largest metropolises, despite the concentration of resources, the majority of the urban population in India will probably remain beyond the reach of critical services, unless urgent efforts are made. The situation of the urban poor today is appalling, not only in India but in many developing countries. To change their situation does not require new knowledge or technology but rather new approaches and the will to act in favor of the disfranchised for the well being of all.