Week 3 (July 2nd – July 8th)

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I can’t believe I am at week 3 already! Time has gone faster than I thought. I made a list of things I want to do and places I want to visit before I leave Mumbai. Taking the city tour helped me to decide whether I want to go back to some of the locations that I have seen to appreciate their architecture and history.

During week 3, we were introduced to the Health Infrastructure in Mumbai, India by Dr. Bhatki, Medical Director of the CFHI Program “Confronting Tropical Disease Challenges in Mumbai”. These lectures were given in the morning at the MLSM office in Santacruz (East). In the afternoons, we visited the office of Dr. Potnis in Jogeshwari (East).

Dr. Bhatki works as Joint Director (Training and Surveillance) and as Monitoring and Evaluation Officer (GFATM/PPTCT) at Mumbai District AIDS Control Society since 2006. He has dedicated most of his medical career to the study and treatment of leprosy in India. He supervises paramedical workers and field workers in community based programs. The programs last 4 weeks long at each location. Physicians, paramedical and field providers work an average of 5 to 6 hours per day. These programs are privately funded and act independently from the local and national health assistance that India provides its citizens. “Even though the government provides basic healthcare, patients preferred to pay to see a private physician because of the quality of medical care, accessibility, trust on the physician and time saving” Dr. Bhatki said.

To better understand the socio-economic reality of Mumbai, we went over some very important facts that reflect the causes of overcrowding, and poor public health in the city.

Mumbai it is the most populous city in India, and the fourth most populous city in the world. Mumbai is also one of the world’s top 10 centers of commerce in terms of global financial flow. Due to the high migration of workers from the rural areas to find better job opportunities Mumbai suffers from the same major urbanization problems seen in many fast growing cities in developing countries: widespread poverty and unemployment (all the ones that migrate and are unable to find jobs), poor public health and poor civic and educational standards for a large section of the population. With available land at a premium (to rent a 15 square feet room in Dharavi cost an average of $120.00 dollars. You could only fit 3 twin size sleeping bags right next to each other in such small place), Mumbai residents often reside in cramped, relatively expensive housing, usually far from workplaces, and therefore requiring long commutes on crowded mass transit, or clogged roadways. It is estimated that 50% of the population live in slum areas or a slum like where there is usually no proper sanitation, electricity, or telephone services (although most of the people own a cell phone!).

To my surprise, the literacy rate in Mumbai alone is of 94.7 %, higher than the national average of 86.7%. Although there is a high percentage of literate population in the city due to migration, the level is well below the world average literacy rate of 84%, and India currently has the largest illiterate population of any nation on earth.Despite government programs, India’s literacy rate increased only “sluggishly” and a 1990 study estimated that it would take until 2060 for India to achieve universal literacy at then-current rate of progress There is a wide gender disparity in the literacy rate in India: effective literacy rates (age 7 and above) in 2011 were 82.14% for men and 65.46% for women.  The low female literacy rate has had a dramatically negative impact on family planning and population stabilization efforts in India. Studies have indicated that female literacy is a strong predictor of the use of contraception among married Indian couples, even when women do not otherwise have economic independence. There is an aim in increasing female literacy rate up to the point that primary and secondary education is provided without a charge to the parents. Up to some years back, the community looked down an India family if the females in the family were sent to attend college. Progression in cultural beliefs are being made and with that people are changing their mind sets about approving females having the right to an education.

There are 4 main literacy programs implemented in India:

National Literacy Mission

Sarva Siksha Abhiyan

Non-governmental efforts as Rotary Club and Lions Club

Mamidipudi Venkatarangaiya Foundation

The main objectives that these organizations have in common is for all children, males and females, to complete five years of primary schooling and eight years of secondary schooling and an opportunity for promoting social justice through basic education.

Most of the literate population lives in slums, which is a very contrasting reality with the literate population in the United States. The United Nations Educational, Scientific and Cultural Organization (UNESCO) has drafted a definition of literacy as the “ability to identify, understand, interpret, create, communicate, compute and use printed and written materials associated with varying contexts. Literacy involves a continuum of learning in enabling individuals to achieve their goals, to develop their knowledge and potential, and to participate fully in their community and wider society. A literate person in America would be able to find at least a minimum wage job and live in a neighborhood that looks nothing like a slum in India.

One of the critical problems facing India’s economy is the abysmal gap between social-economic classes. Poverty in India is widespread, with the nation estimated to have a third of the world’s poor. In 2011, World Bank states, 32.7% of the total Indian people falls below the international poverty line of US$ 1.25 per day while 51.7% live on less than US$ 2 per day. Since the 1950s, the Indian government and non-governmental organizations have initiated several programs to alleviate poverty, including subsidizing food and other necessities, increased access to loans, improving agricultural techniques and price supports, and promoting education and family planning. These measures have helped eliminate famines, cut absolute poverty levels by more than half, and reduced illiteracy and malnutrition.

Although the Indian economy has grown steadily over the last two decades, its growth has been uneven when comparing different social groups, economic groups, geographic regions, and rural and urban areas.

While other Asian countries like China, Singapore and South Korea started with the same poverty level as India after independence, India adopted a socialist centrally planned, closed economy. Fortunately India has started to open its markets since the economic reforms in 1991, which has cut the poverty rate in half since then. Another cause is a high population growth rate, although demographers generally agree that this is a symptom rather than cause of poverty.

Water supply and sanitation in India continue to be inadequate, despite longstanding efforts by the various levels of government and communities at improving coverage. A number of innovative approaches to improve water supply and sanitation have been tested in India, in particular in the early 2000s. Most Indians depend on on-site sanitation facilities. Recently, access to on-site sanitation has increased in both rural and urban areas. In rural areas, total sanitation has been successful. In urban areas, a good practice is the Slum Sanitation Program in Mumbai that has provided access to sanitation for a quarter million slum dwellers.

India’s water crisis is predominantly a manmade problem. India’s climate is not particularly dry (I was there during the monsoon season! I got soaked everyday!), nor is it lacking in rivers and groundwater. Extremely poor management, unclear laws, government corruption, and industrial and human waste have caused this water supply crunch and rendered what water is available practically useless due to the huge quantity of pollution. In managing water resources, the Indian government must balance competing demands between urban and rural, rich and poor, the economy and the environment. However, because people have triggered this crisis, by changing their actions they have the power to prevent water scarcity from devastating India’s population, agriculture, and economy.

This mismanagement has significant negative health impacts in the population including diarrhea, from chronic diseases, respiratory problems, skin disorders, allergies, headaches and eye infections that only add up to the already existing health care crisis.

Some of the most important recommendations given by physicians to their patients are to boil the water before consuming it, and let it boil for about 5 to 10 minutes to ensure that pathogens are killed. Other purification systems include installation of a filtration system at home (which due to the cost not many can afford), and the use of chlorination tablets.

In India, prostitution (the exchange of sexual services for money) is legal, but a number of related activities, including soliciting in a public place, owning or managing a brothel, pimping and pandering, are crimes. Prostitution is one of the reasons for the uncontrollable spread of sexually transmitted diseases (STDs) in Asia. The lack of use of barrier devices among prostitutes and their clients has been cited as a factor in the spread of HIV in India. As a result, prevention campaigns aimed at increasing condom use by sex workers have been attributed to play a major role in restricting the spread of HIV in this country.

A factor that has contributed to the increase in HIV spread and prostitution is the establishment of a human trafficking hub center in the city that incites sexual exploitation, labor trafficking, begging, adoption, drug smuggling and peddling and organ transplants.  In the heart of Mumbai, lies Kamathipura, one of the country’s poorest districts and also its largest red light district, home to more than 60,000 sex workers. For the pimps and brothel owners of Mumbai, the sex industry is a multi-million dollar business in which money, not health, is the bottom line. The highest prices go for the youngest girls, many of whom have been kidnapped from other countries and trafficked to India, or sold by their own families into the industry.

India’s effort to protect victims of trafficking varies from state to state, but remains inadequate in many places. The government has prohibited some forms of trafficking for commercial sexual exploitation through the Immoral Trafficking Prevention Act (ITPA), but these laws are ineffectually enforced and their penalties are not sufficiently stringent with a maximum of ten years imprisonment and/or fines.

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