This paper discusses the health implications of urban slums in modern India. The geographical history of the subcontinent will be discussed as it pertains to the formation of modern Indian culture, including a discussion of India’s once pristine and now largely polluted river system. A historical background will also be given, discussing the multiple invasions and colonization of the subcontinent and the impact that has had on the economic and social wellbeing of the country. The caste system, which was implemented nearly three thousand years ago, still plays an integral role in the dynamics of Indian culture and is the primary reason that so many people have been living in poverty for centuries. 1
This analysis will also cover the history and impact of slums; though the impact assessment will focus mainly on the human condition, an environmental element will also be discussed. The various health impacts will be analyzed in detail and the scope of the problem will be uncovered.
A set of two unique examples will be given to address possible solutions to the problem of the slums, each with a very different, but effective approach. The challenges of dealing with large-scale slums from political and economical perspectives will be addressed, including whether or not to eliminate slums entirely or to improve the lives of people who currently live there. In addition, a large section of this paper will be devoted to taking a serious look at a comprehensive solution to slum dwelling.
Please note: References are cited within the text as comprehensive footnotes.
1 G. Bongard-Levin, A History of India (Progress Publishers: Moscow, 1979) p. 27.
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Approximately 180 million years ago India broke off of Pangaea and was an island continent located to the south of Asia. Fifty million years ago, due to the shifting of the tectonic plates, it collided with Asia in a massive impact that created the Himalayan mountain range; the impact of the collision is still causing the Himalayans to grow by the year.2 The geographical impact of the Himalayas is essential to the political and cultural development of India. Because the mountain range is so vast, and so tall (it is home to the largest mountain in the world) and it borders the warm tropical waters to the south it created a diverse, yet often lush set of microclimates in the India environment. 3
The cool, dry air in the Himalayas draws warm, moist air from the southern seas inland across the subcontinent, as the precipitation gathers in the warmer months it causes massive monsoons to occur on a yearly basis. Riverbeds flooded and created lush fertile land over most of southern India and its coastal regions. It was on the banks of these great rivers that the largest civilization of the Bronze Age was born and continued to flourish. 4
2 G. Bongard-Levin, A History of India (Progress Publishers: Moscow, 1979) p. 11. 3 Wood, Michael. (2007) The Story of India. Episode 1. London, England.
4 . Majumdar, Dr R. C; Pusalkar, Dr A. D. (2003) Ancient India. p 650, Dr V. D. Mahajan; History and Culture of Indian People, The Age of Imperial Kanauj, p 50.
A large shift in the global climate caused a change in the monsoon pattern and the once lush floodplains of east India dried, causing drought across the area. To the west however, once arid land was becoming more fertile as the onset of rain brought it to life.
The political borders of India have changed and the Incus civilizations, which traditionally were a part of the subcontinent, now lay within the borders of Middle Eastern countries outside of India. India sits at the base of the Asian continent and protrudes like a large peninsula. It has a vast coastline and is bordered by Pakistan to the east, China, Bhutan and Nepal to the north, and Burma and Bangladesh to the west. To the south, India rests between the Arabian Sea and the Bay of Bengal. There are seven major rivers that run through India and multiple tributaries that stem from them. It has a varied terrain, which includes flat plains, deserts, high mountains and the Himalayas. By geographical standards it is the seventh largest country in the world, though its population is the second highest and is projected to be the most populous country in the world by 2020.5
India was home to some of the most complex, and oldest civilizations in history. All humans alive today, who are not of African ancestry, can trace their lineage back to India. Some families in India, who practice a traditional religion and with it the practice of marriage to first cousins, have in their genotype evidence of genetic markers which match DNA found in ancient humans. 6 Evidence of early homosapians suggests that approximately eighty thousand years ago, there was a movement of people up from Africa, they trekked across Arabia and into India where many settled and created great civilizations. The monsoons created land that
5 CIA. (2013) CIA World Factbook: India. Retrieved April 28th 2013 from: https://www.cia.gov/library/publications/the-world-factbook/geos/in.html
6 Wood, Michael. (2007) The Story of India. Episode 1. London, England.
was suitable for agriculture, it created rivers that allowed trade and travel, it provided fresh water, and it supplied ample resources fish and game to thrive; essentially, the monsoons created a utopian location for any metropolis.
The following map depicts the trade routes between the three prominent civilizations of that time, Egypt, Mespotamia, and Harappa.
According to archeological studies, a shift in climate change approximately ten thousand years ago caused the monsoon pattern to shift and move to the west. The rivers that the Incus valley civilizations were built upon essentially stopped flowing. Famine, thirst and disease plagued the dying metropolis and those who were able to, migrated west for more fertile land. The beginning of modern India starts with this migration.
7 Corse, Theron. 2009. Map of Harappa. Tennessee State University. Retrieved May 2nd from: http://faculty.tnstate.edu/tcorse/h121/Harrapamap.jpg
The instability caused by this mass movement, along with the yet unclaimed territories made India a prime target for invasion. The earliest invasions of India can be traced back to approximately 1000 BCE. Due to its prime location for trade within Europe, China and the Middle East, invasions continued and culminated with the British Rule in the early 1800s.
Political/Social and Economic Background
India gained its independence from British Rule on August 15th 1947, and has remained independent since that time. It still functions under a legal system similar to that of the English, with a few exceptions. Certain religious groups are susceptible to different laws based on their beliefs, but this largely functions as common and not written law.
Like in its early history India is still a prime location for trade and has many natural resources. India is home to the second largest coal reserves in the world, and also has reserves of iron ore, manganese, mica, bauxite, rare earth elements, titanium ore, chromite, natural gas, diamonds, petroleum, limestone, and plentiful arable land. 8 Additionally it has 1,911 cubic kilometers of total renewable water resources and only withdraws 761 cubic kilometers worth of water per year. Still the country has several threats to its livelihood; India has a rapidly growing population, limited resources, an ever-expanding income gap, and is susceptible to natural disasters. Though India’s GDP for purchasing power parity is fourth in the world, at over four trillion, nearly thirty percent of the population is living below the poverty line, many in India’s growing urban slums.
8 CIA. (2013) CIA World Factbook: India. Retrieved April 28th 2013 from: https://www.cia.gov/library/publications/the-world-factbook/geos/in.html
Area of Concern
What is a Slum?
The United Nations gives the following definition of a slum:
A group of individuals living under the same roof in an urban area who lack one or more of the following:
1. Durable housing of a permanent nature that protects against extreme climate conditions.
2. Sufficient living space, which means not more than three people sharing the same room.
3. Easy access to safe water in sufficient amounts at an affordable price.
4. Access to adequate sanitation in the form of a private or public toilet shared by a reasonable number of people.
5. Security of tenure that prevents forced evictions
The largest slums in India all fit into this description, and have dire health impacts for the people who inhabit them.
9 UN-HABITAT (2005), Urban Indicators Programme Phase III.
10 United Nations, World Urbanization Prospects; The 2003 revision.
Health Hazards of Slums
The multitude of health hazards associated with slum dwelling can be grouped into five categories: Built Environment, Overcrowding, Utilities, Sanitation, and Health Management.
Homes that are built in slums often consist of very little more than corrugated tin propped up on other pieces of scrap metal. They are structurally unsound, often made of hazardous materials and susceptible to collapse. One of the substantial risks to individuals who live in slums is the threat of a natural disaster. An earthquake or fire, which would prove detrimental in a suburban neighborhood or a city, would be catastrophic in a slum.11 Not only are more people liable to be injured in such an event, but it is also more difficult for relief workers to bring aid to the area because slums lack the infrastructure, such as paved roads and fire hydrants, that would make relief efforts successful. Additionally, the materials used to build homes in slums can be highly flammable, catalyzing a small event into a catastrophe.12
11 Iol. (2005) Toxic Waste Causing Disease in Somalia. Iol News. Retrieved May 3rd, 2013 from: http://www.iol.co.za/news/africa/toxic-waste-causing-diseases-in- somalia-1.235531#.UYnK3yusZig
12 JackCaravanos,KevinChatham-Stephens,BretEricson,PhilipJLandrigan, Richard Fuller, The burden of disease from pediatric lead exposure at hazardous waste sites in 7 Asian countries, Environmental Research, Volume 120, January 2013, Pages 119-125, ISSN 0013-9351, 10.1016/j.envres.2012.06.006. (http://www.sciencedirect.com/science/article/pii/S0013935112001892)
Most homes within urban slums are single room dwellings packed tightly against one another. There are multiple people living in a one-room space, which provides very little privacy, in addition to promoting the spread of disease. The single room of these dwellings is used to cook, to sleep and for recreation. Indoor cook stoves release smoke and other inhalants that can be extremely hazardous to the wellbeing of the inhabitants. 13
Overcrowding within the individual homes is certainly detrimental to the health of the residents, but the overcrowding of the slums as a whole provides an added layer of health hazards. Lack of green space and the culmination of human waste lead to pest and parasite infestations.
Slums are essentially large garbage heaps where people happen to live; they have no running water, no electricity, and no public works (garbage, street cleaning etc.). Water borne illness is common, due to non-potable water as the main, if not only source of drinking water. Lack of electricity means no heat in the colder months and no air conditioning in the hotter months, which leaves the elderly and children more susceptible to temperature related conditions. Without public works, slums are prone to pest infestations and the culmination of hazardous wastes. People who live in slums sometimes earn a living by collecting scraps from waste sites. The problem with this is that they could be collecting toxic and/or hazardous substances and bringing those substances home without even knowing what they are doing.
13 K. Chatham-Stephens et al. Burden of disease from toxic waste sites in India, Indonesia, and the Philippines in 2010. Environmental Health Perspectives. Published online May 4, 2013.
Lack of sanitation is one of the largest problems that inhabitants of slums have to face. There are no sewers, so people are forced to use the bathroom anywhere there is space and the omnipresent human waste is one of the largest factors contributing to disease. Not only does it make for aesthetically unappealing living conditions, but that factor combined with the fact that there is no potable water, means that people’s water sources are often contaminated with human sewage.
Health management is nearly impossible in slums. Health care professionals have a very difficult time navigating slums and stopping the spread of disease, and those who are chronically ill have little to no access to health care services. The massive burden of disease coupled with the limited access to preventative and curative services exacerbates an already challenging problem.
Scope of the Problem
One third of the world’s urban dwelling population lives in slums. The largest slum in India in 2006 had approximately one million people in it, and it is now listed as only the fourth largest slum in India, meaning that over four million people, and probably many more still live in urban Indian slums. 14 Estimates suggest that within India’s population, which consists of over a billion people, hundreds of millions of people live in slums.15
14 Bendickson, Jonas. (2010) The Places We Live. Retrieved May 2nd 2013 from: http://www.theplaceswelive.com/
15 Unger A, Riley LW (2007) Slum Health: From Understanding to Action. PLoS Med 4(10): e295. doi:10.1371/journal.pmed.0040295
Slums exist all over the world and though they remain a significant problem in many areas, certain individuals have come up with innovative and impactful solutions to certain aspects of the problem. Two individuals, who have made huge contributions to the well being of inhabitants of slums, are discussed in this section.
Partners in Health
Partners in Health is an organization founded by Dr. Paul Farmer to face the growing health challenges in developing countries, specifically as they pertain to infectious disease. Paul Farmer worked in the slums of Haiti with Tuberculosis patients, and discovered a growing faction of individuals who were infected with multi-drug- resistant Tuberculosis (MDRTB). Despite the insistence from his colleagues that MDRTB could not be treated in slums due to logistical limitation, Dr. Farmer took on the challenge and won. Dr. Farmer developed a program to have individual volunteers hand deliver the medications to patients and watch as they took each dose. This process had a very high success rate and was able to cure many cases of MDRTB that other physicians would have though impossible. 16There was no medical innovation involved, simply the idea that it was possible to help. This notion is key to improving the lives of slum dwellers across the globe.
16 Abraham, Curtis. "Because we're all worth it.(Paul Farmer )(Interview)". Student Resource Center - Gold. Gale, Oct 11, 2008.
Advocacy and Awareness
One of the reasons that slums have been so neglected by the health community is that they are indeed very easy to neglect. Slums are outside of large cities, far from the suburbs and inaccessible by car. Slums, and their inhabitant are easy to avoid all together if that is the intention; but one activist changed all of that. The following picture is from a project produced by Parisian street artist “J.R.”.
This is an example of his advocacy art on the rooftops of slums in Kenya. JR took photographs of the inhabitants of the slums and enlarged them onto vinyl sheets to use as roof coverings. Most importantly they provided shade and protected the inhabitants from the rain; but they were also on the flight path into the areas largest airport. All individuals who flew into the area, and looked down, no longer saw nameless inhabitants, and nondescript brown buildings, they saw the faces of the people living in them, looking up as if to say “I see you too.”
17 Proctor, Aaron. (2011) [Tenacity] "Inside Out," JR's Global ArtProject. Fast Forward. Retrieved May 2nd 2012 from: http://fwdlabs.com/blog/inside-out-jr- global-art-project/
This advocacy art garnered attention worldwide and has spawned some of the most comprehensive public heath and humanitarian efforts ever to touch these areas; all simply because people knew that they existed.
There are many challenges when it comes to developing a solution to the environmental and human impact of slums. The scope of the problem is so large and the facets of the issue so diverse, that it seems an impossible task to manage. There is no single solution to managing the impact of slums, and each individual project will be costly both in materials and man-hours.
Scope certainly has to be considered when assessing the challenges of slums. What form will the solution take? Is the aim to eliminate the slum all together or is the aim to improve the lives of the people currently living there? If the aim of a program is to eliminate the slum, where will the people go?
Cost is a huge factor addressing these challenges. Most slums exist in areas that are either entirely impoverished, or have a huge gap in the class system with certain wealthy factions and large impoverished groups. It is all well and good to get people out of slums, but in order for it to be sustainable they need to have a way to earn an income and be self-sufficient. Additionally the cost of cleaning the slum from an environmental impact is astronomical, there have not even been assessments of all of the biohazards and toxins present in slums, so municipalities, or even country governments would have to start from ground zero.
The most promising solutions for addressing the problem of slums are creative ones. Paul Farmer’s innovative one on one technique solved an infectious disease problem that was thought impossible. “J.R” ’s activist art gave a face to a vast group of forgotten people and began a global movement. Though the problem is grandiose, I think that the solution will be a multifaceted and creative one.
There needs to be coalition of humanitarian, health, political and environmental groups, who work as a think tank in order to come up with comprehensive solutions. Although the ultimate goal is to make it so that no one is forced to live in a slum there are intermediary steps to improving the situation. First, the people living in the slums need to have access to basic necessities, clean water, and sanitation. This can be done in a myriad of ways, from shipping in bottled water to cleaning India’s abundant water sources. Secondly, there needs to be a way to manage the human waste. There are all sorts of innovative ways of doing this; researchers in China even invented a toilet that can turn human waste into energy by converting it to methane gas used to power buildings. 18 If even one self-sustaining public bathroom could be build for every 1000 people in a slum the burden of disease could be cut down significantly. Thirdly there needs to be a political and global reform, which makes slums unacceptable. Because the garbage that accumulates in slums comes from the entire globe, people all over the world need to change their habits.
18 Nanyang Technological University (2012, June 26). New toilet turns human waste into electricity and fertilizer.ScienceDaily. Retrieved May 5, 2013, from http://www.sciencedaily.com/releases/2012/06/120626072942.htm
In the global market people need to focus on buying locally what they can and buying fair trade goods in all other cases. Developed countries have become so materialistic that they no longer understand that their goods are coming at the cost of someone else’s well being. This will have to be a massive cultural shift, and it will take time, but with awareness projects like “J.R.” ’s it is possible.
The modern problem of slums in urban India can trace its roots back over three thousand years, but simply because there has not been a solution yet, does not mean that a solution is not possible. This analysis looked at the problem from cultural political and environmental perspectives, and discovered that despite the almost insurmountable nature of the problem there are innovative individuals working successfully to make a change. The diverse and lengthy history of India, paired with its robust economy makes it a unique, but not impossible challenge. There is so much money in India’s economy, and so many people capable of innovation that an eventual solution is inevitable. The key to finding it is to making people care, getting the public involved and mounting political pressure on a global and local scale to make a change. The biggest change that can be made is through the pocketbooks of people. If consumers are more aware of what they are buying and refuse to buy goods that contribute to the ills of developing countries, and society as a whole, not only will the slums improve, but the humanity as a whole will benefit.