|Priorities in Health and Nutrition of the Urban Poor: The Case of the Calcutta Slums (CRED, 1991, 18 p.)|
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.