KCCI / 2012 – 04 Disease Load in Aliganj, an Urban Village in New Delhi, India: A Search for Directions in Risk Reduction through Urban Planning Bhuvaneswari Balan Sara Elazan Miguel Morillas Andreas Sandberg In collaboration with Department of Community Medicine Vardhman Mahavir Medical College New Delhi Disclaimer The views expressed in this case-study are those of the authors alone and do not necessarily reflect the policies or the views of UNICEF and/or Vardhman Mahavir Medical College’s Department of Community Medicine. Contents Acknowledgements 1 List of Acronyms 2 List of Figures and Tables 3 Foreword 4 Executive Summary 5 Introduction 7 1.1 Urbanization and urban living 7 1.2 Urban health, vulnerabilities, and the urban poor 8 Background 11 2.1 Urban growth and spatial expansion 12 2.2 Aliganj: An urban village in Delhi 13 Purpose, Methodology, and Limitations of the Study 16 3.1 Aim 16 3.2 Objectives 16 3.3 Data sources and analysis 16 3.4. Limitations 18 Findings 19 4.1 Demographic findings 19 4.2 UHTC findings: Disease patterns 21 4.3 Findings of in-depth interviews 24 4.4 FGD findings 26 4.5 Key informant interview findings 29 Discussion 30 5.1 Disease load 30 5.2 Behavioural risk factors 30 5.3 Environmental risk factors 31 5.4 Social determinants 36 Conclusion 38 Recommendations 39 7.1 Long-term recommendations 39 7.2 Short-term recommendations 39 References 43 Annexures 46 Acknowledgments This study would not have been possible without the generous support and cooperation of many individuals. Firstly, we would like to thank UNICEF India’s Knowledge Community on Children in India (KCCI) programme for enabling this study, and Mr. Sarbjit Singh Sahota, UNICEF New Delhi for his constant guidance. We extend our sincere gratitude to the faculty and residents at Vardhman Mahavir Medical College’s Department of Community Medicine, including Dr. Deepak Raut, Dr. Neelam Roy, Dr. Richa Talwar, and Dr. Anita Khokhar for hosting us, and to Dr. Prashant Jarhyan, Dr. Shailaja Daral, and Dr. Diksha Sabarwal for mentoring us and helping to frame and execute the study. Additionally, our thanks are owed to Dr. Vinoth, Dr. Akanksha, Dr. Ali, Dr. Timiresh, Dr. Randeep, Dr. Parth, Dr. Mrinmoy, Dr. Abha, Mr. Vikas Choudhary, and Mr. Deepak Bhardwaj for their vital role in our study’s research process. We are indebted to the key informants for their insights, particularly Professor KT Ravindran for enabling us to gain a contextual understanding of Aliganj, our study site, and organizing a workshop for us to interact with his colleagues. Dr. Mayank Mathur (SPA) provided valuable assistance during our field visit to Aliganj. The breadth of urban planning information we obtained would not have been possible without the help of Professor Kavas Kapadia (SPA), Mona Anand, Rajiv Kadam (CEPT), Kirtee Shah (ASAG), Manvita Baradi (UMC), and Sunil Mehra (MCD). From our participation at the urban planning workshop held at UNICEF New Delhi on July 12, 2012, we received additional inputs and valuable advice from Kanak Tiwari (IUDI), Sanjay Kanvinde (IUDI), Ranjit Mitra (IUDI), Dr. Rabidyuti Biswas (SPA), Vinod Dhar (IUDI, DDA), and Dr. Srihari Dutta (UNICEF). Our thanks also go to those at UNICEF who took time to meet with us, including Dr. Pavitra Mohan, Dr. Jagadeesan, and Dr. Vinod Anand. Above all, we express our deep appreciation to the residents of Aliganj who generously shared their stories, opinions, homes, and lives with us. We are grateful to them for allowing us to come into their lives, if only briefly, and we hope this study and its follow up actions will help us give back part of what they have given us. - The authors, July 2012 1 List of Acronyms ASAG Ahmedabad Study Action Group CEPT Centre for Environmental Planning and Technology, Ahmedabad CSDH Commission on Social Determinants of Health DDA Delhi Development Authority DUA Delhi Urban Agglomeration FGD Focus Group Discussion IDIW In-depth Interview IUDI Institute of Urban Designers – India KCCI Knowledge Community on Children in India LPG Liquid Petroleum Gas MCD Municipal Corporation of Delhi MLA Member of the Legislative Assembly SPA School of Planning and Architecture, Delhi SPSS Statistical Package for Social Sciences, Data Analysis Software UHRC Urban Health Resource Centre UHTC Urban Health Training Centre UMC Urban Management Centre, Ahmedabad UNESCAP United Nations Economic and Social Commission for Asia and the Pacific UN-HABITAT United Nations Centre for Human Settlements UNICEF United Nations Children’s Fund URTI Upper Respiratory Tract Infection VMMC Vardhman Mahavir Medical College 2 List of Tables. Figures and Images Tables Table 1: Population growth of Delhi, 1951-2011 Table 2: Projected Population in Delhi Settlements (in millions) 12 Table 3: Age distribution in Aliganj 19 Table 4: Gender- and Age-wise distribution of most prevalent diseases 23 8 Figures Figure 1: Duration of stay in Aliganj 20 Figure 2: Gender-wise categorization of age groups in Aliganj Figure 3: Diagnoses of symptoms in Aliganj UHTC 21 21 Figure 4: Gender-wise distribution of UHTC diagnoses in Aliganj 22 Figure 5: Distribution of disease burden among age groups 23 Images Image 1: Lane in Aliganj 33 Image 2: Sewage and water lines crossing 34 Image 3: 35 3 Foreword The Knowledge Community on Children in India (KCCI) is a partnership between the Government of India and UNICEF, the aim of which is to fill knowledge gaps and promote information sharing on policies and programmes related to children in India. In 2012, under the aegis of this initiative, over 40 graduate students from India and across the world undertook fieldwork and documented initiatives focused on child rights and development. Their vibrant perspectives, commitment and hard work are reflected in these studies, published by UNICEF. Eleven initiatives were documented in 2012. The teams looked at a range of initiatives at different levels of intervention – from public grievance redressal programme in Madhya Pradesh to impact of disasters in children. The lens applied to these studies is to identify the essential elements that go into making a model intervention successful and sustainable. UNICEF recognises the potential and power of young people as drivers of change and future leaders across the globe. The KCCI Summer Internship Programme aims to support the development of a cadre of young research and development professionals with an interest, commitment and skills in promoting and protecting children’s rights. UNICEF will continue this collaboration with young researchers, the Government of India and academia, so as to bring fresh perspectives and energy to development research and showcase examples of how it is possible to ensure that the rights of every child in India are fulfilled. Louis-Georges Arsenault Representative UNICEF India 4 Executive Summary The convergence of health and urban planning has received scarce research attention in India. Due to rapid rates of urbanization and complex economic, social, and political factors, urban centres are attracting high numbers of people from rural settings, including many poor looking for work in cities. New Delhi, India’s capital is one such city, with a high urbanization rate characterized by a great number of people living in unauthorized and/or unplanned settlements. One type of settlement that attracts migrants is the urban village, where many homes have been constructed in an unplanned, haphazard manner. While there is a link between poor living situations and poor health, the disease load in urban villages has been underexplored in research. This study’s aim is to understand the disease load in Aliganj, an urban village in the south zone of the National Capital Territory of Delhi, India in order to identify causes of ill health that can be addressed through urban planning. To determine urban planning recommendations, the study navigates the constellation of social, historical, political, and economic forces that determines the health risk factors in the said locality. The study employed two sets of secondary data from the Department of Community Medicine, Vardhman Mahavir Medical College to understand the disease load of the given population, including an Aliganj health census as well as records of health centre visits by Aliganj residents. These were complemented by three sources of primary data, including discussions and interviews with community members, key informants in the field of urban planning, and municipality representatives. The findings revealed that the median family size of a household is 4.5 members. The population consists of a higher proportion of adults between the 20 to 39 age group (52 per cent), with a predominance of young males and a recent migrant population with the duration of stay being less than five years (46 per cent). The findings on disease burden revealed high numbers of upper respiratory tract infections (URTIs) and gastrointestinal problems. Children under 5 years of age had the highest presented cases of URTIs, and women between 20 and 39 years showed the highest number of gastrointestinal problems. The in-depth interviews with community members indicated that poor quality of water, overcrowding, congestion, poor ventilation, lack of green and open spaces, and inadequate garbage disposal mechanisms were some of the key concerns within the household and community in general. The focus group discussion with house owners gave insight on the evolution of Aliganj and the resulting developments, both positive and negative. Though provision of basic services and amenities were in place, there is a certain degree of apathy that the residents face resulting from poor platforms to voice their concerns and neglect and delays in repairs of existing structures. 5 The findings corroborate the existing body of literature on the disease burden of populations living in overcrowded spaces with substandard living conditions and amenities. The behavioural risk factors associated with disease occurrence in Aliganj included lack of water treatment, unsafe water storage practices, and poor knowledge on prevention of illnesses. Poor ventilation was one of the most important environmental risk factors reported at the household level, especially among the population group categorized as tenants. Other commonly cited factors included overcrowded houses, fly breeding spaces (as a result of proximity of livestock to living spaces), and poor garbage disposal mechanisms. Living in an area characterized by narrow lanes and tall, unplanned and congested or even unsafe housing structures, the community is vulnerable to disasters, making emergency measures difficult to implement. Inadequate town planning and the leniency in enforcing building regulations has resulted in the existing deplorable situation of unhealthy, unsafe, and overcrowded structures bursting at the seams. Lack of incentive for property owners to improve housing conditions is a consequence of the growing demand for affordable housing. The problem of poor quality housing is further compounded by the insecure tenure status among tenants who are mainly migrant labourers without economic leverage and lacking the social cohesion needed to demand improved housing conditions. Accordingly, planning and implementation for better living conditions should involve multiple stakeholders and be executed at parallel levels. The present study provides recommendations for short-term implementation directed at immediate concerns and long-term recommendations addressing the overarching structural and regulatory aspects. Some of the immediate recommendations include in-situ upgradation to provide better facilities without relocation, and provision of awareness and education on healthy behavioural practices. Among long-term recommendations, the required improvements in infrastructure with the involvement and input from the community and other stakeholders need to be explored. Administrative and development plans need to embrace urban villages as an integral part of the city and draw up feasible and contextually sound strategies for improvement. Systems that are transparent, accountable, and well coordinated are crucial for effective implementation of urban village development as for any development activity. 6 Introduction The convergence of health and urban planning has received scarce research attention in India. With ever more people moving into urban areas to pursue livelihoods, there is a need to enhance understanding not only of housing needs and structures, but also of health outcomes. The urban poor face great health inequity as a result of existing social and economic structures. Health indices do not comprehensively capture the vulnerabilities of the urban poor as compared to other income groups. Addressing disparities in health and living requires an understanding of the ‘causes of causes’, which include various environmental, social, and political factors. The present research is one such attempt to understand the disease load and the associated risk factors among the urban poor. This report begins with an overview of urbanization and urban health in the context of urban poor in India. The background chapter elaborates on the cultural, political, and economic evolution of Aliganj, the site of the study. The objectives and methodology sections describe how the study was carried out, the chosen sources of data, the process of analysis, and limitations. Subsequent chapters present the study’s findings, discussion, and conclusions. The study ends with multi-level long- and short-term recommendations to improve the factors influencing health and living conditions. 1.1 Urbanization and urban living Urbanization has recently become a powerful force, with over half of the world’s population already living in urban areas.1,2 Most of the world’s population growth in the twenty-first century is expected to occur in urban settings, much of it in Asia and Africa.3 The UNESCAP and UNHABITAT report Housing the Poor in Asian Cities estimates that by 2030, 54.5 per cent of the Asian population will be urbanized, which implies that one out of every two urban residents in the world will be in Asia.4 India has 23 urban centres, each containing over one million people, reflecting an urgent need to learn how to effectively deal with such large populations.5 Between 1991 and 2001, India 1 Archana Ghosh, Urban Environment Management (2003): 1. 2 ICSU Planning Group, “Health and Wellbeing in the Changing Urban Environment: a Systems Analysis Approach,” (2011): 6. 3 Ibid., 10. 4 UN-HABITAT and UNESCAP, “Housing the poor in Asian cities,” Quick Guides for Policy Makers Guide 1 (2008): 2. 5 Alison J. Barrett and Richard M. Beardmore, “Poverty Reduction in India: Towards Building Successful SlumUpgrading Strategies,” Human Settlement Development. (2000): 328. 7 had an average population growth rate of two per cent, while urban India, mega cities, and slums grew at three, four, and five per cent respectively.6 Delhi, India’s capital is one such mega city that has seen a high growth rate. The urbanization rate of Delhi is 93.01 per cent, and its geographical space has expanded from 201 square kilometres in 1951 to 792 square kilometres today.7 As of the 2011 Census (Table 1), Delhi has a population of 16,753,235 people.8 Table 1: Population growth of Delhi, 1951-2011 Year Total pop. Total urban pop. Urban pop. % Decennial urban growth % 1951 1,744,072 1,437,134 82.4 - 1961 2,658,612 2,359,408 88.8 64.2 1971 4,065,698 3,647,023 89.7 54.6 1981 6,220,406 5,768,200 92.7 58.2 1991 9,420,644 8,471,625 89.9 46.9 2001 13,782,976 12,819,761 93.0 51.3 2011 16,753,235 16,333,915 97.5 21.0 Source: Census of India, 2011 1.2 Urban health, vulnerabilities, and the urban poor Urban living has become a reality for a vast majority of people globally. The urban environment can be defined as “the natural, built and institutional elements that determine the physical, mental and social health and well-being of people who live in cities and towns.9 An urban area can have a profound impact on the health of its citizens. While urban environments can offer economies of scale, they may also come with “congestion and institutional overload.” 10 Box 1. Definition of Urban Area All statutory places with a municipality, corporation, cantonment board or notified town area committee, etc. - A place satisfying the following three criteria simultaneously: - A minimum population of 5000 - At least 75% of male working population engaged in non-agricultural pursuits - A density of population of at least 400 per square kilometre. - Census of India, 2011 6 Siddharth Agarwal et al., “State of Urban Health in Delhi,” Ministry of Health and Family Welfare, Government of India (2007): 3. 7 Sohail Ahmad and Mack Joong Choi, “The Context of Uncontrolled Urban Settlements in Delhi”. ASIEN 118 (2011). 8 “Delhi Population Census,” http://www.census2011.co.in/census/state/delhi.html. 9 ICSU Planning Group, “Health and Wellbeing,” 9. 10 Ibid., 6. 8 The Indian Census defines an area as urban if it meets three criteria (See Box 1). In India, 25.7 per cent of the urban population is below the poverty line.11 A crowded urban lifestyle constrained by poverty shapes urban health and determines risk factors of the urban population. Differences in health among population groups that are systematic, socially produced and unfair is an inequity in health. - WHO, “Urban HEART.” As an area of study, Urban Health accordingly looks at the relationship between an urban context and the distribution of health and disease in the urban population.12 While it is evident that health status across populations can and will differ, health inequity is becoming a growing concern in urban spaces, where there is an increased vulnerability of certain populations as a result of existing social hierarchies and structures.13 The unfair distribution of power, money, and resources needs to be tackled in order to address the health inequity.14 Regrettably, the urban poor and their health concerns seldom get the attention they deserve.15 The State of Urban Health in Delhi report, prepared by the Urban Health Resource Centre (UHRC), highlights the importance of understanding urban health from the perspectives of the different socioeconomic layers of the population. It also identifies vulnerability factors of the urban poor among whom the health status indicators are significantly worse than in the middle and high income groups.16 Vulnerability … [is] … a situation where people are more prone to face negative situations and there is a higher likelihood of succumbing to them. - Agarwal et al., “State of Urban Health in Delhi.” The urban poor often face “inadequate housing and sanitation, lack of running water, poor or under-nutrition, overcrowding, indoor pollution, substance abuse, violence, loss of social support, poor access to healthcare, increased vulnerability to extreme temperatures or climatic events such as flooding or drought, and lack of participation in decision-making.” 17 With rapid and 11 Agarwal et al., “State of Urban Health in Delhi,” 3. 12 Sandro Galea and David Vlahov, “Urban Health: Evidence, Challenges, and Directions,” Annual Review of Public Health 26 (2005): 342. 13 WHO, “Urban HEART: Urban Health Equity Assessment and Response Tool,” The WHO Centre for Health Development (2010): 11. 14 CSDH, “Closing the gap in a generation: Health equity through action on the social determinants of health,” Final Report of the Commission on Social Determinants of Health, Geneva, World Health Organisation (2008): 10. 15 Agarwal et al., “State of Urban Health in Delhi,” 4. 16 Ibid. 17 ICSU Planning Group, “Health and Wellbeing,” 11. 9 unplanned urbanization, a large number of migrants are attracted to cities that are not equipped to house them. Migrants who move to city areas typically earn wages from the informal sector and do not have sufficient savings to live in a healthy environment or formally planned colonies. Urban migrants may live in slums or other marginalized environments that make them more vulnerable to health hazards, morbidity, and mortality.18 Although health indices are typically better in urban than rural areas, the urban poor that live in these types of inadequate settlements may experience health outcomes that are worse than those observed in rural areas.19 While the above mentioned are some of the immediate causes of poor urban health, the importance of addressing the ‘causes of causes’, namely the structures, hierarchies, and socially determined conditions in which people grow, live, work, and age is crucial for a long term solution in tackling health inequity.20,21,22 Urban planning is a process of control and design of the urban environment to ensure effective development of settlements and communities. - Taylor, “Urban Planning Theory Since 1945.” The field of urban planning has merged with public health in order to tackle urban health concerns and outbreaks of diseases. However, as the public health model adopted a more biomedical approach, it resulted in a divergence between urban planning and health. Urban planning, furthermore, provides few answers to concerns around health and space utilization. This has consequently ended in unsuccessful attempts at understanding the spatial, economic, political, and social factors that create health inequity.23 This lacuna is visible not just in practice, but also in research and academia in general. The present report recognizes this gap and seeks to address it through a case study focusing on the interface between urban health and urban planning in an unplanned settlement in Delhi. 18 Agarwal et al., “State of Urban Health in Delhi,” 4. 19 ICSU Planning Group, “Health and Wellbeing,” 11. 20 WHO, “Urban HEART,” 6-7. 21 CSDH, “Closing the gap in a generation,” 3-6. 22 Michael Marmot, “Social determinants of health inequalities,” Lancet 365 (2005): 1099-1104. 23 Jason Corburn, “Confronting the challenges in reconnecting urban planning and public health,” American Journal of Public Health 94 (2004): 541. 10 Background The outline of Delhi is defined by a mixture of residential developments, which broadly can be classified as planned and unplanned settlements.24 Planned settlements are those that have been constructed (i.e. authorized) by concerned government agencies. In the development of housing in such settlements, issues pertinent to the establishment of congenial and sustainable living conditions (physical, social, and economic issues, among other aspects of city planning) have been taken into consideration.25 Unplanned settlements are, by contrast, areas and zones of residence that have evolved with little or no such involvement. Only 24 per cent of Delhi’s settlements are planned, with a majority of the population living in unplanned settlements.26 Unplanned Settlements in Delhi Unauthorized colonies: Residential pockets established by private developments on encroached land. Through official regularization, such colonies variably attain legal status. Urban villages: Settlements that have developed erratically beyond the jurisdiction of authorities, and therefore often are devoid of water, drainage, and sanitation arrangements. Jhuggi-Jhopdi clusters: Squatter dwellings on illegally occupied land, where infrastructure and services often are sub-standard or non-existing. Slums: Notified slum areas (unlike JJ clusters) are catered for by the authorities and enjoy a certain degree of service provisioning, although living conditions generally are poor. Resettlement colonies: Settlements established in the urban periphery for relocation of JJ households, yet often defined by infrastructural deficiencies and debilitating living standards. - Ahmad and Choi, “The Context of Uncontrolled Urban Settlements.” Delhi’s unplanned settlements are characterized by various levels of haphazardness as well as inconformity with building laws and formal housing standards. Since the composition of localities varies, differentiation between types of unplanned settlements is essential. Reviews of unplanned settlements note that categorization is feasible on the basis of parameters such as tenure security, living conditions, status of infrastructure, and degree of authorized development in the locality. Delhi’s spatial representation of unplanned settlements ranges from temporary squatter dwellings to more or less permanent multi-story residential complexes. Principal categories include unauthorized colonies, resettlement colonies, urban villages, slums (notified 24 M. Ishtiyaq and Sunil Kumar, “Typology of Informal Settlements and Distribution of Slums in the NCT, Delhi,” Journal of Contemporary India Studies: Space and Society, Hiroshima University 1 (2011): 37. 25 Ibid. 26 Ahmad and Choi, “Context of Uncontrolled Urban Settlements,” 79. 11 and non-notified), Jhuggi-Jhopdi clusters, among other informal and low-key living arrangements.27 2.1 Urban growth and spatial expansion Demand for land and housing in Delhi has grown considerably in times of urbanization and rapid population growth. By the beginning of the previous century, vast areas of rural land and village properties were acquired under pressure from the city’s rising needs.28 Around the period 1908 to 1909 and the era following the establishment of New Delhi as the capital in 1911, the colonial administration demarcated areas for habitation within boundaries of lal dora (meaning “red thread”) and consequently, major changes in livelihoods and structural arrangements were due.29 Villagers deprived of lands for cultivation and livestock keeping were either reallocated elsewhere or provided (meagre) compensation for lost deeds. Peripheral villages were gradually engulfed within the city; a process through which they “acquired urban characteristics due to reduction in ... agricultural base [and by] transformation into residential or industrial colonies.”30 Table 2: Projected Population in Delhi Settlements (in millions) Type of settlements 2004 2005 2006 2011 2021 JJ Clusters 2.30 2.37 2.45 2.82 3.41 Slum Designated Areas 2.96 3.05 3.15 3.63 4.39 Resettlement Colonies 1.97 2.04 2.10 2.42 2.93 Unauthorized Colonies 0.82 0.85 0.87 1.01 1.22 Regularized Unauthorized Colonies 1.97 2.04 2.10 2.42 2.93 Urban Villages 0.99 1.11 1.05 1.21 1.46 Planned Colonies 3.67 3.79 3.91 4.50 5.44 Rural Villages 0.82 0.85 0.87 1.01 1.22 Total Population 15.50 16.09 16.50 19.00 23.00 Urban villages are tantamount to localities of change, encompassing elements of both urban and rural. They are characterized by ambiguity in relation to the surrounding cityscape, not only in terms of spatial evolution, but also with reference to cultural customs and settlement patterns as well as formal frameworks of policy and legality. Historical records suggest that some 25 rural villages were brought into the urban fold two decades following the establishment 27 Ibid. 28 K.V. Sundaram and V.L.S. Prakasa Rao, “Metropolitan expansion in India: spatial dynamics and rural transformation,” in Understanding urban revolutions: Development planning and agrarian change ed. Tim BaylissSmith and Sudhir Wanmali (New York: Cambridge University Press, 2009), 286-288. 29 P.P. Shrivastav, “Report of the Expert Committee on Lal Dora and Extended Lal Dora in Delhi,” (2007): 15. 30 Halima Begum, “Addressing Planning Problems for Territorial Integration of Urban Villages in Delhi: A Case Study of Masoodpur,” Jahangirnagar Planning Review 1 (2005): 1. 12 of Delhi as the capital city, and that number had grown by another 22 villages by 1951.31 Other sources suggest fewer initial numbers. For instance, the first Delhi Master Plan (adopted in 1962) declared 20 villages located within the urban area as urban villages. Currently, about 135 to 165 urban villages exist in Delhi and house an estimated 1.21 million individuals, as seen in Table 2,32 accounting for about seven per cent of Delhi’s total population in 2011. Despite such growth, physical and social parameters surrounding people and their health in these spaces, as previously noted, have elicited sparse research attention — a gap this study addresses to some extent through a case study of one such unplanned settlement located in the south zone of Delhi. Traditionally, research on urban housing conditions and health has centred on slums, as these typically contain some of the poorest populations in cities and urban areas. The less poor, though still marginalized groups, have received less attention.33 Commentary on urban poverty in India has pointed out the necessity to focus on vulnerable populations living beyond “typical” slum settings. Agarwal, for instance, underscores the need to pursue “better counting of the number and proportion of uncounted ... disadvantaged city dwellers.”34 Urban villages generally include residents that cannot afford living conditions typical of more properly planned areas. As seen through literature reviews, there is a lack of knowledge on the interaction between urban villages and health.35 Additionally, while there is sufficient evidence on the role urban planning can play in determining health needs and addressing them, there is little coordination between the two sectors in Delhi or in the country as a whole. These limitations suggest the need for additional research that focuses on these aspects. 2.2 Aliganj: An urban village in Delhi Aliganj is an urban village in Delhi’s south zone and positioned administratively within the Kotla Mubarakpur ward.36 This locality is situated on lands whose history as an area of habitation dates back to the 15th century. The settlement’s contemporary contours took shape mainly after the capital project, an era seeing increasing population movements due to industrialization, the India-Pakistan partition, and pull-forces of urban sprawl.37 The urban transformation can be 31 Ibid. 32 Sohail Ahmad, Mack Joong Choi and Jinsoo Ko, “Quantitative and qualitative demand for slum and non-slum housing in Delhi: Empirical evidences from household data,” Habitat International (2012): 4. 33 Sunil Prashar, Rajib Shaw and Yukiko Takeuchi, “Community action planning in East Delhi: a participatory approach to build urban disaster resilience,” Mitigation and Adaptation Strategies for Global Change (2012). 34 Siddharth Agarwal, “The state of urban health in India: comparing the poorest quartile to the rest of the urban population in selected states and cities,” Environment & Urbanization 23 (2011): 27. 35 Corburn, “Reconnecting urban planning and public health”. 36 Bishwajit Banerjee, “Efficient Plantation Strategies for Urban Villages in New Delhi” (paper presented at Programme for World in Denmark, Copenhagen, Denmark, June 28, 2012): 3. 37 Sundaram and Rao, “Metropolitan expansion in India,” 286. 13 traced along these processes, and it is a chronology during which migrants, refugees, and reallocated families have come to establish themselves in an ever-expanding scope. Meanwhile, land owning residents experienced pressures to shift from agrarian lifestyles to renting property and housing as their principal source of income (see Annexure 1 for a timeline of major events in Aliganj since 1911). Changes in occupational patterns occurred in tandem with (uncontrolled) construction of multistory buildings and residential premises high in demand. Additions of floors and housing units subsequently translated into relative wealth among the landowning community, but they also came with burdens of overcrowding and congestion. Implications of this evolution echo amidst the principal population groups in Aliganj: a minority of long-term residents who own and rent out accommodation to a larger population mainly consisting of (temporary and short-term) migrant labourers. This pattern mirrors Aliganj’s character as a residential area that is mainly populated by transitory low-wage earners who live and work in the surroundings of Delhi. The geography bordering Aliganj and the other village localities of Kotla Mubarakpur (Kotla, Pilanji, and Jor Bagh) is shaped by metropolitan growth that emerged in the late 1950s and 1960s.38 The Defence Colony and the South Extension residential schemes developed south of Aliganj during this time. Other localities in the vicinity include Kidwai Nagar and Lodi Estate (upmarket residential areas) and Sewa Nagar (government colony). Map 1: Location of Aliganj within National Capital Territory of Delhi (maps not to scale) Sources: Census of India 2011, Office of the Registrar General, and Google Earth 38 Ibid. 14 Strong reasons for Aliganj’s unchallenged expansion are rooted in the historical demarcation of residential areas within the limits of lal dora, which over time, in practice, has come to exempt these urban enclaves from application of building byelaws. The first Delhi Master Plan (adopted in 1962) outlined an ambition to include urban villages within the city’s formal urban planning framework. However, this ambition has never materialized despite more recent visions outlined in both the second and third generation of master plans (respectively revised in 1990 and 2007).39 Other factors that account for Aliganj’s unplanned evolution can be traced to shifts in governance arrangements that were instigated in the post-independence era, and notably the formalization of responsibilities and regulatory mechanisms that historically have resided with informal institutions at the village level (such as the panchayat, village elders, and the nambardar).40 However, the spatial profile of settlements like Aliganj testifies to the fact that the government institutions, including Delhi Development Authority (DDA) and Municipal Corporation of Delhi (MCD), which were established to manage issues related to urban development, have not taken cognizance of the complexities of urban villages to effectively include them as integral areas of planning.41 Haphazard outcomes accordingly are characterized by housing structures featuring spatial extensions in all directions. A majority of Aliganj’s buildings extend above five floors and are typically constructed with minimal space in-between. On the positive side, tenure security does not present critical issues to house owners since their plots have been acquired lawfully through purchase, inheritance, or construction on allocated land. Tenants, on the other hand, lack such benefits of security in their leased household units, which tend to be more depleted compared to the owners’ homes. Because of the vast discrepancies between owners’ and tenants’ living conditions, this study keeps in mind the differences between the two population categories. 39 DDA, “Master Plan For Delhi: with the perspective of the year 2021,” (2007). 40 V. Ghaneshwar, “Urban Policies in India – Paradoxes and Predicaments,” Habitat International 10 (1995): 295. 41 Begum, “Addressing Planning Problems,” 1. 15 Purpose, Methodology, and Limitations of the Study 3.1 Aim To understand the disease load in an urbanized village in the south zone of National Capital Territory of Delhi, in order to identify causes of ill health that can be addressed through urban planning. 3.2 Objectives (1) Measure the disease load among various population groups in an urbanized village in the south zone of National Capital Territory of Delhi. (2) Explore environmental and social risk factors associated with the identified morbidities. (3) Identify behavioural patterns that could contribute to disease occurrence. (4) Produce recommendations for urban planning strategies to mitigate the disease load in unplanned urban settlements. 3.3 Data sources and analysis The present study is a product of UNICEF’s KCCI Summer 2012 Internship and was carried out during May through July 2012 in collaboration with Safdarjung Hospital and Vardhman Mahavir Medical College’s (VMMC) Department of Community Medicine. The study draws on five sources of data. The disease load data resulting from the health census survey and the Urban Health Training Centre (UHTC) data were obtained from secondary sources from the datasets maintained by the Department of Community Medicine, VMMC. In addition, the researchers collected primary data through in-depth and key informant interviews, a focus group discussion (FGD), as well as through structured sampling of observations in the community. The study adopts a mixed method approach relying on analytic triangulation of the results obtained through the various modes of data collection. 3.3.1 Data on clinic visits from the urban health training centre (UHTC), Aliganj The outpatient registry of the UHTC in Aliganj was analyzed to understand the disease patterns for which medical attention has been sought at the centre. The data covers the period from March 2012, when the centre was set up, to June 2012. All records (n=883) from this period were converted from the hand written document to electronic format and analyzed using SPSS version 16 and Microsoft Excel 2007. 16 3.3.2 Health census survey, VMMC, 2012 The Department of Community Medicine at VMMC had undertaken an extensive health census survey in the area of Aliganj prior to the setting up of the health centre. The survey covers the entire population of Aliganj to understand, among others, its demographic composition and the prevalence of acute and chronic illnesses. The VMMC data was analyzed using SPSS to ascertain demographic and health trends. 3.3.3 In-depth interviews Pilot interviews using an interview guide were conducted with tenants and owners of houses in Aliganj. The interview guide (Annexure 2) was subsequently revised to exclude unnecessary or inappropriate questions and add questions regarding themes that emerged during the pilot interviews. Social workers and doctors familiar with the Aliganj area and known to the residents escorted the researchers to potential interview sites. Researchers interviewed residents of 20 households from Aliganj, chosen purposively based on the following criteria: ! Tenants should be the majority interviewed, as they were assumed to be the most marginalized in the area (living in worse housing conditions and having little power to change their housing conditions). ! Tenants from different housing floors should be interviewed. Early observations suggested that living conditions may differ between floors in the same building. ! No less than half of the interviewees should be females, given that they are at home longer than males, contribute more to household chores, and have less power to change their situation. An observation checklist (Annexure 3) was employed along with the interview guide to ascertain living conditions, structure, and amenities. Data from the interviews were analyzed to detect recurrent issues and themes in the interviewees’ responses. 3.3.4 Focus group discussion (FGD) An FGD was conducted among the house owners of the community (see Annexure 4 for the discussion guide) to encourage a candid discussion on life in Aliganj, health concerns, environmental concerns, changes and development over the years (both positive and negative), and suggested areas of improvement. A thematic analysis of the data gained from the FGD helped in deciphering pertinent themes and concerns of the house owning community. 3.3.5 Key informant interviews and discussions The findings on disease burden and determinants of identified morbidity patterns were presented to urban planners in order to obtain suggestions and recommendations to make urban living spaces healthier (see Annexure 7 for a list of key informant interviews). 17 3.4. Limitations ! As the data for both the UHTC registry and the Aliganj health census survey were not collected by the present study’s researchers, they had no control over the types of questions asked or how the data were recorded. Aliganj health census survey forms, for instance, were filled out by different social workers whose reporting style may have varied in the absence of a uniform guideline. ! The UHTC registry was indicative only of the number of visits to the centre and not necessarily the number of people visiting. Doctors working at the UHTC commented that some patients could come multiple times during a single illness episode. ! The empirical value of the UHTC registry should be judged keeping in mind that the centre is relatively new and functions only in the morning hours. ! During in-depth interviews, the researchers were unable to ask questions directly in Hindi and relied on social workers or doctors who worked as translators. A certain degree of interviewee bias from the above factor therefore cannot be ruled out. ! As the present study was carried out during a period of ten weeks, the disease load may not have fully captured seasonal variations in disease patterns or the transitional migrant status of a majority of the population. 18 Findings Using a mixed method approach, triangulation of empirical data on disease load and findings from in-depth interviews, the FGD, and key informant interviews allow for a comprehensive understanding of the circumstances of disease occurrence in Aliganj. 4.1 Demographic findings The population of Aliganj consisted of 4138 individuals and 1800 households.. The median household size in Aliganj was 4.5. The median household monthly income was Rs. 10,000. Table 3: Age distribution in Aliganj Age dist. Freq. % < 5 years 359 8.7 5-10 years 382 9.2 10-20 years 552 13.4 20-40 years 2150 52.0 40-60 years 548 13.3 > 60 years 140 3.4 Total 4131 100.0 Table 3 provides information on the age distribution of the population. More than half the population fell under the 20-40 years age group, which reflects the large number of migrant labourers who reside in Aliganj often for short periods of time. As shown in Figure 1, the majority of residents (23.86 per cent) have lived in Aliganj for less than two years, and the next highest group (22.55 per cent) has lived there between two and five years. Taken together, almost half (46.41 per cent) of the Aliganj residents have lived in the area under five years. 19 Figure 1: Duration of stay in Aliganj Figure 2 presents the gender composition of the population from where it is seen that more males than females were residing in Aliganj, and males were predominant in all age groups. The gender differential was most noticeable in the 20-40 years age group. 20 Figure 2: Gender-wise categorization of age groups in Aliganj 4.2 UHTC findings: Disease patterns The UHTC of Safdarjung Hospital and VMMC has been working in the Aliganj community since February 2012. Based on an analysis of its outpatient records, Figure 3 presents morbidity patterns among patients seeking consultation at the UHTC. Figure 3: Diagnoses of symptoms in Aliganj UHTC 21 Upper respiratory tract infections (URTIs) characterized by cough, cold, and fever, among other symptoms, were the most observed illnesses, capturing 35.9 per cent of the cases. At 21.3 per cent, the second leading cause of illness was shown to be gastrointestinal problems, which included diarrhoea, gastritis, and vomiting. The next dominant categories were musculo-skeletal problems and micronutrient deficiencies. Figure 4: Gender-wise distribution of UHTC diagnoses in Aliganj Figure 4 presents gender differences in the disease patterns at the UHTC. Although on surface and on aggregate, gender differences do not appear to be great for the various diseases, and especially for those causing the highest morbidity, the age-wise observations reveal noticeable gender differences as seen in Table 4. 22 Table 4: Gender- and Age-wise distribution of most prevalent diseases Diagnosis < 5 yrs 5- 9 yrs 10- 19 yrs 20- 39 yrs 40- 60 yrs > 60 yrs M F Total M F Total M F Total M F Total M F Total M F Total Upper respiratory tract 38 30 68 25 15 40 34 27 61 36 49 85 22 24 46 6 11 17 24 12 36 12 2 14 11 13 24 27 42 69 8 23 31 6 8 14 0 0 0 2 0 2 7 7 14 4 23 27 14 18 32 7 15 22 1 3 4 1 0 1 6 4 10 3 41 44 1 14 15 2 11 13 63 45 108 40 17 57 58 51 109 70 155 225 45 79 124 21 45 66 infections Gastrointestinal problems Musculoskeletal problems Micronutrient deficiencies Total The top four issues presenting at UHTC for treatment were analyzed to determine age-specific disease burden among women and men. Age-wise analysis of diseases shows that women in the age group of 20-39 years had a considerably higher number of gastrointestinal problems and micronutrient deficiencies compared to men in the same age group. Additionally, they had the highest burden of said diseases among all age groups. Children below ten years of age carried a notable burden of URTI with a little over 60 per cent of overall morbidity related episodes (Figure 5). Figure 5: Distribution of disease burden among age groups 23 4.3 Findings of in-depth interviews The in-depth interviews assessed disease occurrence and behavioural factors predominantly among tenants. The findings resulting from the interviews are included below. 4.3.1 Disease load The interviews focused on ascertaining an illness episode in the household since January 2012. Interviews revealed a majority of sampled households (n=16) reported some form of ailment. The most frequently reported acute illnesses were respiratory-related such as cough, cold, and fever, followed by gastrointestinal problems like diarrhoea and vomiting. Chronic and acute observed ailments included jaundice, cardiovascular disorders, tuberculosis, and infertility. Half of the respondents associated diseases with seasons, with specific reference to gastrointestinal problems during the rainy season and complaints of cold and cough during winter. Water was perceived as a main cause of illnesses in Aliganj. Water quality was perceived as a potential cause of diarrhoea (n=11), while “consumption of cold water” and sudden “temperature swings” were associated with cold and cough. Congestion, overcrowding, and lack of ventilation in the immediate living environment (within the household and in the locality) were cited as the major concerns that could affect health. Unhygienic conditions were considered as another major cause of diarrhoeal diseases. A majority of respondents could not provide suggestions for improvement as many of them associated their inability to change anything with their insecure tenure status as tenants. Whereas a majority showed sound knowledge of the causes of common ailments (such as water-borne contagion and URTI), few conveyed the same level of understanding regarding disease prevention. Only a small portion made a comment on how to prevent URTIs (n=4); the rest did not provide any information or expressed helplessness about what could be done regarding URTI prevention. One respondent (the only homeowner in the chosen sample) reflected on the importance of limiting ghettoized housing structures for rentals in order to prevent further overcrowding. Intensity of disease was quoted as the main determining factor in the choice and utilization of healthcare alternatives. No treatment was used by many respondents for minor health complaints like headaches and muscle pains. For acute illnesses (cough, cold, and diarrhoea), the first response for many respondents was to procure drugs over-the-counter or self-medicate without seeking medical advice (n=9). For serious health concerns, a majority of respondents reported seeking treatment at either private clinics or government hospitals. 24 4.3.2 Environmental and social determinants Household level A majority of the observed houses (n=17) consisted of only one room, which was used for all household activities, including cooking and sleeping (see Annexure 5 for a rough sketch of a typical tenanted one room dwelling). Of the houses observed, more than half (n=13) had no door or window facing an open space. Drinking water in Aliganj was supplied from the Delhi Jal Board, which typically was available for two hours each in the morning and evening. Ground water from a private well was used in some instances (n=4) exclusively for cleaning and washing purposes. Most households (n=13) did not have a water tap inside the house. A single source of water was shared by an average of 5.5 households. Few houses had toilets for private use (n=2), while the majority shared a common toilet (n=16) either on the same floor or a different floor. An average of 4.9 households used one common toilet, in total averaging 16.7 persons per toilet. Environmental level The street drainage system was perceived as insufficient (n=11). Concerns related to water logging, especially during rainy season, were frequently highlighted. However, it was asserted that the drainage system has improved over the years. Three-fourths of the respondents had at least one complaint in regard to the living conditions in the neighbourhood. Many respondents cited overcrowding and littering as pressing environmental concerns (n=6). Other important issues included poor garbage disposal mechanisms, lack of open spaces, and poor drainage. None of the tenants kept any livestock, but it was observed that several households (n=6) had cows in the vicinity that were kept by the owners. Five out of these six respondents complained of stench and flies as a result of cattle keeping. Flies in the streets were also observed and reported as a common concern linked to garbage accumulation. 4.3.3 Behavioural factors Ventilation For cooking, liquid petroleum gas (LPG) was ubiquitously used in the houses. The residents find this fuel affordable, most readily available, less polluting than conventional methods, and a quicker alternative. The majority of interviewees (n=15) use some form of ventilation while cooking. The most common ventilation method was keeping doors and windows open. Of the observed households, less than half (n=6) had an exhaust fan installed in the premises. 25 Water storage and treatment Water for cooking and drinking was stored in plastic bottles or clay pots and kept inside the house. Water quality was generally perceived as good. While many respondents (n=13) complained of unclear, odorous, and muddy water at times, more than half of the respondents (n=11) reported not treating their drinking water at all. Only six treated the water when found necessary, mainly determined by water smell, colour, and sometimes taste. Disposing waste Garbage was generally stored inside the house in small bins, which were emptied once per day. Some reported taking the garbage to the dumping place near the nallah, the open drainage canal on the periphery of Aliganj. Owing to irregular removal, garbage accumulation occurred in the streets, resulting in fly breeding spaces and blockage of open drains and pipes. 4.4 FGD findings The FGD brought together house owners from Aliganj to discuss a variety of topics. The key themes emerging from the FGD are highlighted below. 4.4.1 Aliganj: Then and now Respondents expressed nostalgia for the past when conditions in Aliganj, according to them, were better because of less population, open space, and wider streets. 4.4.2 Negative developments The house owning residents claimed that the government acquired their land and did not provide jobs, so renting out their property was the only way to make money. Importantly, though they blamed the government for not providing proper jobs or development services in return for their land, they also blamed themselves for the unplanned construction they undertook of their own volition. “We have dug our own graves by overstepping the permissible construction limits. If I stretched the permissible limit by half a foot, the next person overstepped the limit by two feet, and so on until all the streets have become jammed.” There was consensus about progressive deterioration of the living conditions, especially in terms of congestion and number of people. While in the past (1952) Aliganj was spacious with no migrants, over time, it has seen a substantial increase in population even as the physical size of Aliganj has remained unchanged. Overall, construction of additional tenant housing, along with migrant influx and natural growth, was noted as having contributed to the present unhealthy living outcome. As one way to ease Aliganj’s congestion, the owners wanted portions of the land in the neighbouring locality of Sewa Nagar to be allotted to them, as it had allegedly belonged to them before the government acquired it for development purposes. 26 “Now we have heard that Sewa Nagar is going to be brought down. It’s the decision of the Central Government, so we should be given facility in here … Give us preference to get plots in this area.” 4.4.3 Positive developments Owners perceived the housing structures to be safer than earlier, as they were now constructed with cement rather than the weaker materials used in the past. Basic services also came up in the area, such as the construction of toilets, which reduced open defecation that used to commonly occur. Importantly, while there had been some positive developments, respondents stressed that negligence from authorities caused them to enact some changes by themselves at their own cost. “When we talk about improvement, we had a problem here. We got the road constructed out of our own money, then we also laid down sewage system, got the road made of concrete as well, so thousands of rupees were spent on these. Then for water, we bought pipes from our own money.” 4.4.4 Relationship with authorities The basis for constructing more vertical structures, according to owners, was the government acquisition of their land without job creation. There is a general negative feeling towards the role of authorities, and respondents seemed to agree on negligence in the functioning of their elected officials. Among the key weaknesses in the government’s functioning, the following were mentioned: • Land misuse: The government did not increase the lal dora of the area, thereby limiting land ownership and forcing vertical and excess construction. With no room to develop any more within Aliganj, any land and housing developments must come outside the area. • High rates for utilities and taxation: Owners claimed that they are being taxed equally as the residents in more developed and better maintained neighbourhoods. While the government has been increasing the rates for utilities such as water and electricity in Aliganj, the development in the area had lagged compared to other areas in Delhi. “Many times tenders for streets are issued and streets are shown as repaired and also constructed but all on paper, and money [goes in] pockets.” • Coordination and communication channels: When problems were reported to authorities, they often said that these issues do not fall under their jurisdiction. House owners have experienced a run-around with different authorities sending them to different municipalities, while no one has taken care of the problem. 27 • Corruption: It was stated that tenders for building streets are given to people who do not do the work assigned and instead pocket the sanctioned money. Additionally, workers hired to build or improve the infrastructure have either left the job incomplete or done it shoddily, causing further faults in the system. • Neglect: Owners believe that even when the Municipality’s crews come to repair the roads, they cause more damage than improvement. When they say they will return to finish constructing the roads, they never return. The gap between the sewage and water pipes, which run parallel, has been filled with a degradable material instead of concrete. Respondents also said that they have conveyed their problems to elected representatives and called for solutions, but nothing has come of it. 4.4.5 Relationship with tenants The owners testified that the tenants had no secure tenancy and could be evicted at any time. They recognized that the tenants are assets as they are an important source of income. They considered the housing and services provided to the tenants to be satisfactory and safe, and felt that given the low rents, they could not be expected to provide the tenants with more amenities. Tenants seeking improved amenities (exhaust fan, water filter etcetera) would need to pay higher rent to make improvements affordable. “The tenants are helpless and have no recourse; when [we] say ‘vacate the house,’ they do so… (derisive laughter). If they don’t, then we ourselves throw their stuff outside and evict them.” 4.4.6 Environmental and health issues Sewage and water supply were major concerns, with respondents stating that the drinking water is contaminated. Overcrowding was identified as another common problem that can lead to diseases. Air was perceived to be of poor quality, especially with considerably high population density. Lack of open space was another concern as a contributor to disease occurrence. “We have got diseases because we do not even have parks, because we do not even have schools. Aliganj, Kotla, Pilanji do not have any schools. This is the worst.” In terms of emergency preparedness, while the respondents were aware that there would be no way to save residents from disastrous events, amazingly, there was little concern about or interest in improving the emergency preparedness of the area. “What change can possibly occur in the structure? Already people here have meagre 15 or 20 square yards of land, so where is the scope or the space for expansion? Given the limited land size, any improvement here is impossible.” 28 4.4.7 Recommendations for improvement Respondents were predominantly pessimistic about short-term solutions for the area. With no space to expand, Aliganj offered little scope for improvements. However, respondents did suggest some specific changes that would benefit their locality, including keeping the main road outside Aliganj clean and ensuring the sewage line and water line run separately so there is no risk of contaminating drinking water. They reiterated their demand for the government to allot the land in Sewa Nagar, which the government is planning to re-develop, to the residents of Aliganj, as they see such allotment as the only way for any improvement to occur. 4.5 Key informant interview findings As part of the study, nine unstructured interviews were conducted with key informants (see Annexure 6 for key informants list) including urban planners, urban development managers, architects, and municipality representatives to seek their views and recommendations on tackling the impact of burgeoning urbanization on underserved urban villages like Aliganj and on the health and well-being of those who reside there. As previously noted, there is a dearth of exploration regarding linkages between urban planning and health, which underlines the need for studies to connect disease patterns to urban spaces. In regard to Aliganj, some of the leading concerns pointed out by planners were the linkages between urban planning and water/sewage management, ventilation, and green space. To make any change in the area, many felt that a participatory approach was necessary. In-situ upgradation, which involves upgrading basic infrastructure services without completely rebuilding the entire area, was mentioned by at least two urban planners with others emphasizing a need for small incremental changes. Recommendations for short-term improvement included provision of exhaust fans, solar panel installation, creation of courtyards, and reorganization of the space. Long-term solutions referred to decentralization of urban planning and upkeep of vital amenities such as drainage, making more rental housing available in the city in general, engaging in a public-private partnership, and enlisting a non-governmental organisation or other body to spearhead the process. 29 Discussion Analysis and triangulation of the data acquired from primary and secondary sources sheds useful light on the interface between urban planning and health status of the population residing in Aliganj, as seen in the discussion below (see also Annexure 7 for an illustration of key issues of the study). 5.1 Disease load Morbidity patterns in Aliganj echo in a body of literature that highlights correlations between urban health and living spaces.42,43,44,45 The present study reinforces the commonly held notion that health problems generally link to overcrowding and sub-standard housing. Triangulation of interview materials and discussions with the residents uphold the premise that the living environment in Aliganj bears a negative impact on residents’ health (with a significant overrepresentation of upper respiratory tract infections and gastrointestinal problems). 5.2 Behavioural risk factors Although water was perceived as the main source of contamination, few interviewees reported treating water on a regular basis. The main reason for not treating drinking water was lack of financial resources. Other than boiling water, which is ill-afforded due to the high cost of cooking fuel (such as LPG gas), the residents did not show knowledge of other forms of treating drinking water to ensure its safety. Observations of all interviewed households indicated that they rely on storing large quantities of drinking water given that municipal water is supplied to Aliganj’s residents for only four hours per day. Perceptions of water availability suggested that access to water was believed to be both sufficient and reliable. Nevertheless, storage of untreated water comes with a potential increase in exposure to waterborne contagion. The findings suggest a relatively high degree of awareness among Aliganj’s residents of causes of disease and medically sound treatment options, as well as relevant healthcare alternatives for treating commonly reported diseases. However, with reference to prevention, people’s 42 Agarwal, “State of Urban Health in India.” 43 Galea and Vlahov, “Urban Health.” 44 Corburn, “Reconnecting urban planning and public health.” 45 CSDH, “Closing the gap in a generation.” 30 knowledge, awareness, and behaviour did not reveal the same level of understanding. This points to a gap in both education about prevention and a lack of provisioning of better-quality amenities towards disease prevention, but is compounded by livelihood patterns that, while rooted in Indian tradition and culture, are incongruent with sound ideals of environmental hygiene practices. In the face of illness, multiple factors seem to determine people’s health seeking behaviour, which included knowledge, access, and availability, as well as affordability of healthcare services and perceived seriousness of the illness. Given a complete lack of or inadequate insurance coverage, out-of-pocket expenses are first limited to self-treatment and over-the-counter purchase of drugs. Prolonged illness warrants necessity to visit a medical professional. Delays in seeking qualified treatment and care were often attributed to long waiting time, crowded clinics, and difficulties in access. Such delays and barriers in therapy-seeking exist both at the individual and the infrastructural level. This is largely because health policies for the urban poor have not been prioritized to the same extent as in rural areas.46 Availability and accessibility of healthcare and allied quality aspects are significant factors in terms of determinants of health.47,48 Mapping of healthcare services (pharmacies, health practitioners, and other therapeutic alternatives) available in Aliganj and in the surrounding city was, like analysis of relevant parameters at health sector level (e.g. policy, funding mechanisms, and history of resource allocation), not practically feasible given the scope of the study and its focus on health-related aspects of urban planning. As accounted for in the previous sections, however, the situation in Aliganj suggests that urbanization and large-scale migration into cities, coupled with poor availability of decent accommodation, corroborates urgent needs to invest both in health system structures and in comprehensive public health, urban planning, and public housing policy (which, specifically and more effectively, can cater to the health concerns and needs of the urban poor). 5.3 Environmental risk factors 5.3.1 Household level Tenant housing in Aliganj typically consists of one-room households with shared toilets and water supply and an average of five households per toilet. The buildings, mostly four- to sixstoried, are closely built with four to eight units on every floor. They have little provision for natural sunlight and ventilation, as windows and doors in observed households opened only to the indoor corridors. This leads to sustained indoor pollution resulting from stagnant air and exhaust from cooking. Lack of ventilation sources exacerbates the risk of respiratory and other 46 Agarwal, “State of urban health in India.” 47 Michael Marmot, “Social determinants of health inequalities.” 48 Sandro Galea and David Vlahov, “Urban Health.” 31 health problems related to poor indoor air quality. A strong barrier to opening doors and windows even where they exist is the lack of privacy resulting from the close proximity to other homes. Few tenants with no windows in the house had installed an exhaust fan for ventilation but by and large neither tenants nor owners expressed major interest in installing such devices for ventilation. Overcrowding refers to a situation in which more people are living within a single dwelling than there is space for, so that movement is restricted, privacy secluded, hygiene impossible, rest and sleep difficult. - Park, “Park’s Textbook of Preventive Social Medicine.” Observation of the available services and amenities indicated that, on an average, four or five tenant households are required to share a single toilet and bathroom space which reportedly does not get cleaned everyday. Shared hygiene spaces with irregular water supply in crowded living arrangements inevitably position people in harm’s way of communicable diseases such as gastrointestinal infections.49 “Where one family used to live, now five families are living… the space that people have normally for [a] bathroom, we have only that much available for use as our entire living space! So leaving any space [having space to spare] is impossible; especially now when the walls of houses are adjacent to and touching each other.” Data and observations point to a discrepancy between the globally accepted standards and the average number of people per household (room) among tenants. According to the standards prescribed by the World Health Organisation, residents of Aliganj, with a median household size at 4.5 members per unit, are residing in overcrowded conditions that may have a negative impact on their health.50 Another major health concern within the household is the presence of disease-carrying vectors, including rodents, cockroaches and flies. As a residue of traditional livelihood patterns, some house owners keep cattle within their housing premises, often in close proximity to the tenants’ living spaces. This is an unhygienic practice that accentuates the problems of flies and mosquito breeding, especially during warm and rainy seasons, besides adding odour and dampness. 5.3.2 Community level The physical environment of Aliganj is characterized by narrow roads and even smaller bylanes that are sandwiched in between tall buildings blocking off direct sunlight and restricting 49 Sheridan Bartlett, “Urban Children and the Physical Environment,” (nd): 5 50 K. Park, Park’s Textbook of Preventive Social Medicine: 21st edition (2011): 694. 32 adequate ventilation. Delhi is located at the seismic level IV zone for earthquakes.51 Given the proximity of Aliganj’s buildings and constructions not conforming to standards of safety, these are high-risk structures especially vulnerable in the face of calamity. More importantly, any form of emergency operations (evacuation, relief, or rehabilitation) would prove difficult, owing to the encroachment of street spaces and narrowing of passages. Interviews highlight respondents’ awareness of the dangers of such structures and the uncomfortable priority of choosing livelihood over safety. Since tenants are mostly migrants and short-term residents, their attitude towards the living arrangements also suggests forced compromises between affordable accommodation and sub-standard living conditions. Pastoralists by occupation, the original settlers of Aliganj, when presented with no alternative means of livelihood, chose to build and rent out houses as their only source of income. With the ever-growing influx of people migrating to Delhi looking for a better life, demand for affordable housing was and has remained high. These limitations and migration patterns together feed a situation in which incentives for major improvement in housing structures remain at a gridlock. Moreover, urban villages, due to their ‘special status’ often fall under the grey areas of building regulations, resulting in erratic structures that promote unsound living conditions and increased vulnerability to ailments associated with overcrowding and poor housing environments. Image 1: Lane in Aliganj missing In pace with unplanned and uncontrolled development, open and green spaces in the community have diminished. Open community spaces promote well-being as well as a platform for socialization and a sense of belongingness,52 while lack of such spaces creates alienation among 51 “Delhi Disaster Management Authority,” http://delhi.gov.in/wps/wcm/connect/doit_dm/DM/Home/Vulnerabilities/ 52 Galea and Vlahov, “Urban Health.” 33 its members. This sentiment is echoed in the voices of many residents, especially women, who expressed dissatisfaction and concern over the fact that they have no public parks or green spaces and too often remain indoors in the confined environment of their (one room) houses. Lack of safe play spaces for children is not only a health hazard, but poses a risk also of injuries because children are compelled to play on roadsides and in other similarly risky environments. Worse, it curtails the children’s healthy development (physical and psychological) and hampers their imagination (a key developmental milestone for children’s creativity).53 “We do not have any fresh air or good water. Nothing is pure. Just like our streets. You must have seen the filth on the streets. All this has not been done by someone else but by us only, and this is like death for us.” Image 2: Sewage and water lines crossing missing Dangers and risks associated with spending prolonged time indoors within spaces engulfed by pollution, dampness, and insufficient ventilation have been observed in research elsewhere in Delhi, notably affirming indoor air quality and pollution as determinants of respiratory, throat, eye, and skin infections.54 The present study’s analysis of the disease load in Aliganj’s residents corroborates this body of research evidence. Arrangements for water and sanitation in Aliganj were authorized and executed between 1972 and 1973, thus giving due recognition to Aliganj as part of the city of Delhi. However, due to 53 Bartlett, “Urban Children,” 16. 54 Ghuncha Firdaus and Ateeque Ahmad, “Relationship between Housing and Health: A Cross-Sectional Study of an Urban Centre of India,” Indoor and Built Environment (2012). 34 the additions of unplanned structures and buildings, groundwork could not be carried out in a thorough and ideal manner. Maintenance and upkeep subsequently have also been scarce and inefficient. The existing physical area of Aliganj, bursting at its seams, provides little room for improvement and essentially hinders much needed maintenance and re-design, especially of drainage and sewage systems, which run in close proximity to water pipes, occasionally causing contamination. Image 3: missing The poor state of environmental and public health in Aliganj is not lost on anyone who seeks to visit the village. Entering Aliganj, the first troubling sight is the nallah, or the open drainage canal that runs through the entire north of the village. As a result of household waste being discarded in it, in addition to the garbage that is piled on the street (much of which is irregularly collected by Municipal crews), the village appears to be a breeding ground for ill health. The accumulation of garbage and human/cattle waste attracts rodents, flies, and other carriers of disease. While no communal covered garbage bins were observed in the area, availability of such facilities undoubtedly would enhance the sanitary conditions of the village. The social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics. - CSDH, “Closing the gap in a generation.” 35 5.4 Social determinants The social composition of Aliganj consists of two main categories, house owners and tenants. The former attribute the unmonitored haphazard development of their village to circumstances that lie both within and beyond their immediate control. The exploitation by the villagers of the special status given to them has led to the chaotic expansion in physical space over which they claim they now have little control. Although they acknowledge the provision of basic amenities (water, sanitation, electricity, and other services) by the municipal corporation, their demands and requests for repairs or major alterations often go unattended. Villagers’ innate reluctance to fully embrace a healthy urban lifestyle mirrors the Delhi development authorities’ relative apathy towards adopting a more equitable and inclusive approach to urban villages and their development. These negative attitudes feed into each other to create a vicious cycle of neglect and underachievement. Meanwhile, the housing structures from which owners make a living stand in a depleted state, underscoring lack of both incentives and assistance to improve. In turn, these unsafe and unhealthy dwellings continue to contribute to the ill health and lack of well-being of the occupants. As previously noted, the tenants living in Aliganj are largely comprised of migrants who have resided for a period of less than five years (46.41 per cent of the total population, of which half have resided for less than two years). Sharing experiences of poverty and social inequality, they represent a larger segment of Indian society that has been driven astray by a political economy which does not permit them to lead the kind of lives they value in their native places of origin. Looking for a better life and affordable housing, they move into such spaces with little or no tenure security. In this process, they accept to live under conditions that often entail considerable compromises with their health.55 Moreover, anonymity and a lack of social cohesion among migrants, along with expectations and adjoining attitudes over temporary housing options, have the potential to curtail demands of decent living conditions. Under such circumstances, multiple factors operate in joint conspiracy in constraining agency and individual capabilities to enjoy freedoms and opportunities that are pertinent to the realization of a healthy life. Given the bulk of these circumstances at work, it is vital to address concerns at parallel levels that capture individual behaviour and environmental and social risk factors, as well as political and administrative will. Currently, more than 50 per cent of the world’s population lives in urban areas, and that number is expected to grow significantly in coming decades.56 However, planning and management systems are not geared up to handle this demographic shift. This holds true also for India where the rate of urbanization has always remained beyond the organized capacity to grapple the urban growth. Unplanned urban settlements like Aliganj are present day 55 UN-HABITAT and UNESCAP, “Housing the poor.” 56 ICSU Planning Group, “Health and Wellbeing,” 10. 36 testimonies of population movements and social arrangements that put people in precarious situations that all too often are in-conducive to sustained health and well-being. Since overnight changes are not feasible, in-situ upgradation of existing amenities and structures ought to go hand in hand with priorities that are identified by community representatives, whose voices ought to be asserted in order for long-term interventions to be successful. 37 Conclusion Rapid urbanization has corollary implications for housing, health, and access to services and amenities. Unplanned expansion of urban areas and cities can promote evolution and establishment of housing settlements that create specific forms of disease vulnerabilities for the given population. Tackling this scenario through efficient and proactive planning is crucial to ensure the well-being of urban populations, especially the poor and disenfranchised. Literature on urban development and health cautions of the ills of unplanned and chaotic urbanization.57 The study site, with its observed disease load, reinforces the significance of risk factors inherent in the social and physical environment in feeding vulnerability and, as suggested by this study’s findings, disparities in health. The illness patterns among the residents of Aliganj typify the diseases that are prevalent in overcrowded and congested spaces. Poor awareness or knowledge about preventive health and healthy behavioural patterns (for instance, treatment of drinking water) coupled with unhygienic living conditions form a breeding ground for communicable diseases such as respiratory and gastrointestinal infections. Addressing these concerns requires mobilization of multiple stakeholders and resources at parallel levels of urban planning. The process must be enabling and democratic, ensuring participation of all concerned parties (politicians, local residents, and urban planning authorities), wherein sustainable change and development must emerge through a decision making process that acknowledges the opinions of the people. The disease patterns and the associated environmental, social, and behavioural risk factors studied in Aliganj are not necessarily exclusive to this area; they may mirror similar circumstances and patterns in unplanned settlements occupied by the urban poor elsewhere in Delhi, and even in the rest of India’s urban centres.58 Because these concerns may not be unique to the study site, they merit further enquiry on a broader scale throughout Delhi and India. Contextual understanding is vital for successful planning and interventions. Recommendations would not be a magic bullet that could be applied to all contexts given the environmental, social, political, and cultural complexities defining Indian society at large. 57 Agarwal, “State of urban health in India.” 58 Ibid. 38 Recommendations In line with the study’s aim and objectives, empirical findings and discussions with key informants, including urban planners, have informed both long-term and short-term recommendations presented below to address the disease burden in urban village settings like Aliganj, particularly by means of improved urban planning and management as well as by more sound utilization of space and housing structures in the community. Because change in attitudes, responsibilities, coordination, and allocation of resources is needed at various levels in society involving multiple stakeholders, recommendations are presented below along those levels. 7.1 Long-term recommendations 7.1.1 Super-structural Target stakeholders: Policy makers at the state and central government level • Pursue improved transparency and accountability. Funds allocated to public services and infrastructure must be closely monitored to ensure they are being used for their intended purposes. • Seek overlap between urban planning and other policy domains pertinent to poverty reduction and social development. Urban growth is occurring in a large part due to an influx of rural migrants. Rural residents need to have ample opportunity for employment and livelihoods where they already live. 7.1.2 Regulatory Target stakeholders: City- and state-level administrative and monitoring authorities • Design and adopt action plans that integrate urban villages into the formal framework of the city’s planning and development. The absence of measures, institutions, and mechanisms in monitoring building standards in urban villages has led to the haphazard construction of congested housing structures. • Improve coordination between different agencies responsible for regulation, monitoring, and provisioning of services. • Correct the past leniency towards encroachment and ensure construction and tenancy regulations are strictly enforced. In all fairness to Aliganj residents (landlords and tenants), such enforcement must be coupled with improved provision of essential services by Delhi’s urban development authorities and inclusion of residents in decision-making. 39 7.1.3 Housing infrastructure Target stakeholders: Multiple stakeholders including community members, nongovernmental and governmental organisations, administrative authorities, urban planners, and architects • Re-development of congested building structures as per housing regulations must be carried out according to a well-devised plan, with input from the government, residents, architects, and urban planners. • There is need for a government agency or non-governmental organization to take responsibility for overseeing Aliganj’s transformation and organizing the residents’ participation. The village is at a gridlock and change needs to be initiated by an outside source, with integrated inside goals and participation. • Low-cost housing must be provided in a quantity sufficient to meet the needs of the area and the city. Building vertically is a feasible option as long as guidelines are met. • A temporary re-housing location must be determined for the time that the villagers will be out of housing. • Planning for re-housing of Aliganj must keep in mind long-term planning and health concerns. These include the rising prevalence of non-communicable diseases in urban areas, environmental degradation, and overpopulation vis-à-vis considerable shortages of physical space and open areas. • Construct housing with cross-ventilation to provide for better indoor air-quality. This could further enable the reduction of respiratory infections among the residents. • Ample consideration for green and open spaces must be provided. This will not only add to recreational options, but can increase the air quality of the area. • Provide safe pedestrian walkways in the area that are well lit to encourage walking and physical activity. • Establishment of schools and playgrounds in close proximity reduces children navigating through unsafe road spaces on an everyday basis, hence reducing potential risks of injuries. • Any redesign or development should be imbued by democratic principles of implementing a needs-based approach that draws on priorities identified in dialogue with the local community. 40 The long-term recommendations provided are to be considered by urban planners, government officials, and other stakeholders. While these demonstrate the ideal situation and may not be readily achievable, there has to be greater initiative among relevant public (governmental) and private (civil society) stakeholders to enact such changes, rather than continuing to have a stake in keeping conditions as they are. Therefore, while the recommendations should be acknowledged and pursued to their full potential, short-term recommendations are also provided below to help avert worsening of the situation by inducing behavioural changes and facilitating in-situ upgradation of existing structures and amenities. Though short-term recommendations cannot be regarded as solutions to the problems identified in Aliganj, they have the potential to decrease the health burden and contribute to increased overall wellness. 7.2 Short-term recommendations 7.2.1 Housing and neighbourhood infrastructure Target stakeholders: Government officials, urban planners, architects, and the community members • In-situ upgradation: Since complete demolition of whole housing complexes may not be feasible, making small incremental changes through provision of services and amenities without relocating the inhabitants of the community may improve the Aliganj community’s health and living environment. Feasible developments could include paving of roads, upgrading of sewage, and provisioning of open spaces. • Periodic supervision and monitoring by the development authorities, along with strict enforcement of housing regulations will ensure that existing and future constructions abide by the building by-laws. • Re-organizing the physical space in Aliganj will help tackle congestion in streets and other health-related issues. For instance, designating specific spaces for cattle keeping that are situated at a distance from housing spaces but still within the periphery of the village will mitigate dampness and fly breeding which are major complaints. • Provision of courtyards in the middle of buildings need to be explored as a possible technique to enable better ventilation. This may necessitate losing one or two homes in the middle of the buildings to provide for such courtyards. • Provision of communal dustbins on the streets to reduce solid waste accumulation could reduce fly breeding sites, stench, dirt, and clogging of drains. This provision must be a sustainable process with regular disposal mechanisms coupled with educating the community in its usage. 41 7.2.2 Knowledge, awareness, and collective action Target stakeholders: The UHTC working at the urban village level, community members, and the academia and research institutions • Encourage establishment of enabling mechanisms in order to raise demand for better living conditions and greater social cohesion. This could be achieved through the establishment of resident welfare associations, involvement of third party advocacy groups, or grass-root movements. Designate community members to communicate with administrative authorities to ensure coordination and effective dialogue and facilitate timely response to and redress of complaints. • Educate individuals about ways to prevent diseases, which may include raising awareness on the importance of treatment of drinking water. Alternatives that could be considered include, among others, cost-free or subsidized provision of chlorine tablets, a common source of water filtration. • Promote collaboration in research and academia between public health and urban planning in colleges, universities, and other nodal institutions on health and planning for enhanced understanding of the impact of urban spaces on public health and to foster development of contextual best practices. 42 References Agarwal, Siddharth, Anuj Srivastava, Biplove Choudhary, and S. Kaushik. “State of Urban Health in Delhi.” Ministry of Health and Family Welfare, Government of India (2007). Agarwal, Siddharth. “The state of urban health in India: comparing the poorest quartile to the rest of the urban population in selected states and cities.” Environment & Urbanization 23 (2011): 13-28. Ahmad, Sohail, and Mack Joong Choi. “The Context of Uncontrolled Urban Settlements in Delhi.” ASIEN 118 (2011): 75-90. Ahmad, Sohail, Mack Joong Choi, and Jinsoo Ko. “Quantitative and qualitative demand for slum and non-slum housing in Delhi: Empirical evidences from household data.” Habitat International 1 (2012): 1-10. Banerjee, Bishwajit. “Efficient Plantation Strategies for Urban Villages in New Delhi.” Paper presented at Programme for World in Denmark, Copenhagen, Denmark, June 28, 2012. Barrett, Alison J., and Richard M. Beardmore. “Poverty Reduction in India: Towards Building Successful Slum-Upgrading Strategies.” Human Settlement Development 1 (2000): 326333. Bartlett, Sheridan. “Urban Children and the Physical Environment.” (nd): 1-22. Begum, Halima. “Addressing Planning Problems for Territorial Integration of Urban Villages in Delhi: A Case Study of Masoodpur.” Jahangirnagar Planning Review 1 (2005): 1-10. Corburn, Jason. “Confronting the challenges in reconnecting urban planning and public health.” American Journal of Public Health 94 (2004): 541-546. CSDH. “Closing the gap in a generation: Health equity through action on the social determinants of health.” Final Report of the Commission on Social Determinants of Health, Geneva, World Health Organisation (2008). DDA. “Master Plan for Delhi: with the perspective of the year 2021.” (2007). 43 “Delhi Disaster Management Authority.” Accessed 15 July, 2012. http://delhi.gov.in/wps/wcm/ connect/doit_dm/DM/Home/Vulnerabilities/. Firdaus, Ghuncha, and Ateeque Ahmad. “Relationship between Housing and Health: A CrossSectional Study of an Urban Centre of India.” Indoor and Built Environment (2012). Galea, Sandro, and David Vlahov. “Urban Health: Evidence, Challenges, and Directions.” Annual Review of Public Health 26 (2005): 341-365. Ghaneshwar, V. “Urban policies in India – Paradoxes and predicaments.” Habitat International 10 (1995): 293-316. Ghosh, Archana, ed. Urban Environment Management: Local Government and Commmunity Action. New Delhi: Ashok Kumar Mittal Concept Publishing (2003). Government of India. “Census of India 2011, Provisional Population Totals, NCT of Delhi.” Directorate of Census Operations Delhi (2011). ICSU Planning Group. “Health and Wellbeing in the Changing Urban Environment: a Systems Analysis Approach.” (2011). Ishtiyaq, M., and Sunil Kumar. “Typology of Informal Settlements and Distribution of Slums in the NCT, Delhi.” Journal of Contemporary India Studies: Space and Society, Hiroshima University 1 (2011): 37-46. Marmot, Michael. “Social determinants of health inequalities,” Lancet 365 (2005): 1099-1104. Park, K. Park’s Textbook of Preventive Social Medicine: 21st edition. Jabalpur: M/s Banarsidas Bhanot Publishers Ltd (2011). Prashar, Sunil, Rajib Shaw, and Yukiko Takeuchi. “Community action planning in East Delhi: a participatory approach to build urban disaster resilience.” Mitigation and Adaptation Strategies for Global Change (2012). Shrivastav, P.P. “Report of the Expert Committee on Lal Dora and Extended Lal Dora in Delhi.” (2007): 1-52. Sundaram, K.V., and V.L.S. Prakasa Rao. “Metropolitan expansion in India: spatial dynamics and rural transformation.” In Understanding urban revolutions: Development planning 44 and agrarian change, edited by Tim Bayliss-Smith and Sudhir Wanmali. New York: Cambridge University Press (2009): 280-295. Taylor, Nigel. Urban Planning Theory Since 1945. London: SAGE Publishers Ltd., 2004. UN-HABITAT and UNESCAP. “Housing the poor in Asian cities.” Quick Guides for Policy Makers 1 (2008). WHO. “Urban HEART: Urban Health Equity Assessment and Response Tool.” The WHO Centre for Health Development (2010). 45 Annexure I Aliganj timeline 46 Annexure II In-depth questionnaire/interview guide: Aliganj Name Income Age # years in Aliganj HOH Relation to HOH Sex # people in household Rent paid Owner or tenant House type Occupation Disease 1. Which health problems have affected you in the past 6 months? (If none, skip to #3) 2. What do you think might be the cause of these problems? 3. Which health problems have affected your family in the past 6 months? (If none, skip to #6) 4. What do you think might be the cause of these problems? 5. For the family member that had a health problem, what is their occupation? 6. Do you know of any health problems that your neighbours have experienced? 7. Do you feel knowledgeable about how to prevent the diseases mentioned? 8. Do you think your home affects your health in any way? 9. Do you think your home affects your family’s health in any way? 10. Do you think the neighbourhood of Aliganj affects your health in any way? (If no, skip to #12) 11. What do you think could be changed to improve your housing condition? 12. Do you think the neighbourhood of Aliganj affects your family’s health in any way? If no, skip to #14) 13. What do you think could be changed to improve your neighbourhood’s condition? 14. Do you see different diseases during different seasons or they are the same throughout the year? Health-seeking 15. Where do you go if you are sick, and why? 16. Do you ever take any kind of medication without visiting a doctor? Household 17. What type of fuel do you use to cook? 47 18. Why do you use that type of fuel? 19. Do you open a window or door while cooking? 20. Why do/don’t you open any windows or doors while cooking? 21. Does anyone in the house smoke? (If no, skip to #23) 22. If so, do they smoke inside the house? 23. Do you have any livestock? 24. Why do/don’t you have any livestock? 25. Do your neighbours have any livestock? (If no, skip to #27) 26. Do your neighbours’ livestock affect you in any way? 27. Do you have a lot of flies around your home? 28. Do you have a lot of mosquitoes around your home? Water 29. How many hours per day do you have water available? 30. Do you have enough water to cover all your needs? 31. Where do you get your water? 32. How do you store your water, if applicable? 33. Is the water of good quality? 34. How do you determine water quality? 35. Do you treat your water? (If so, record how) Sanitation & Non-human Waste 36. How many people share your toilet? 37. Where do you store and dispose of household waste? 38. Do you think the street drainage system is sufficient? (Prompts: During monsoons; duration of water logging; mosquito breeding; etc.) Final Questions 39. We have observed a high number of diarrhoea cases in Aliganj. What do you think could be causing diarrhoea? 40. How could you prevent diarrhoea? 41. We have observed a high number of respiratory infection cases in Aliganj. What do you think could cause respiratory infection? 42. How could you prevent respiratory infection (ear, nose, throat & cough)? Key Observations/Notes 43. Which behavioural patterns can we note that seem associated with the illness history of the family? 48 Annexure III Observation checklist, Aliganj Urban disease load Interview: Interviewee: WATER AVAILABILITY & SANITATION 1 Availability of water tap 2 Availability of toilet " Inside the " Outside the " On different "Outside the house house, common floor, same building for the floor building " Inside the " Outside the " On different " Outside the house house, common floor, same building for the floor building No. of people " No. of toilets " No. of __________ " Both 3 If toilets shared, number of Houses houses & people it is _________ shared with 4 Do you use MCD/ground water? 5 Mosquito breeding spaces " Only MCD " Only ground water water " Present " Absent " Present " Absent " Present " Absent " Yes " No near household 6 Fly breeding spaces near household 7 Cattle/livestock near household 8 Is there water logging in front of the house? 49 bathrooms OVERCROWDING & HOUSING INFRASTRUCTURE 9 Number of rooms/ occupants in the Rooms Occupants Overcrowding? _________ ________ " Yes " Yes " No " No household 10 Is there a separate room for kitchen? 11 Is cooking done on kitchen table top/ floor " Kitchen table " Floor level top cooking " In the " In the kitchen No windows household ____________ level? 12 Number of windows (if none, skip to #15) _________ 13 Are there windows facing " Yes " No " Yes " No an open space? 14 Are window(s) facing open space in the Electric " No chimney ventilation kitchen? 15 What form of ventilation " Open " Open Door is used while cooking? windows " Exhaust Fan " LPG " Kerosene 16 Fuel used while cooking " Other, specify _________ House No/ Address: ___________________ Type of housing: Only owners / 50 Floor number: ______________ Owners & tenants / Tenants only Annexure IV Focus group discussion (FGD) guide: Aliganj - Owners I. Introduction and general information which includes name, age, and number of years spent in Aliganj. This will be followed by a briefing by the moderator that the discussion is voluntary and all information shared will be kept confidential and will be used solely for purposes of the present research. The participants will also be informed that the discussion will be audio recorded, along with two members taking notes of the entire process. ‘Life in Aliganj’ 1. We have asked for your participation because you all have lived in Aliganj for a long time. How has Aliganj changed while you’ve lived here? 2. What do you think have been the positive developments in Aliganj? (If one of these topics arises, explore it in-depth: toilets, paved roads, sewage, water, electricity, cattle keeping) a. Who was responsible for making improvements? b. Which obstacles did they encounter? 3. What do you think have been the negative developments in Aliganj? (If one of these topics arises, explore it in depth: unplanned development, overcrowding, cattle keeping) a. Why do you think this occurred? b. How does this affect you? c. Do you think this kind of development can have an impact on your health? 4. Imagine that you are part of the ruling committee of Aliganj in charge of promoting people’s health. Which interventions would you recommend? (Ask them to rank changes in order of importance.) a. What can be done to make these interventions at the levels indicated below? · Government level · Local level (MCD, Delhi Jal Board, etc.) · Individual level. b. Have any steps been taken to try to make changes? c. What are the barriers to improving health conditions in Aliganj? 51 5. Are there more people every year coming to Aliganj looking for a place to stay? a. If yes, what happens to them? 6. When you have a problem with services in your neighbourhood, whom do you contact? (If one of these topics arises, explore it in depth: roads, water supply, electricity, sewage, rubbish) a. How easy is it to approach them? b. How long does it take for a remedial action to occur? 7. We have observed that there are houses on the verge of collapse. What should be done with these houses or this land? 8. We have observed that many homes do not have exhaust fans; why is this? Explore who is responsible for the installation, owner or tenant, by asking: What would prevent people from using an exhaust fan? 9. Where do your grandchildren who live in Aliganj typically play outside? a. Why do they go to these places? b. Do you think there should be a provision for the creation of ‘open spaces’ in Aliganj? c. How do you think it can be achieved in the area? 10. What would you do in case of flooding, earthquakes, fire, or medical emergencies? a. Have there been any emergencies in Aliganj? b. How easy is it for an ambulance to reach a house? Introduce them to the concept of urban planning. “Urban planning is a branch of architecture that focuses on organizing and planning cities. This practice was developed to correct problems caused by cities expanding without planning. Urban planning aims to provide a safe, organized, and enjoyable home and work life for residents. Planners also work on removing and/ or prevent the development of unsafe living spaces, as well preserve the natural environment of the area.” What can urban planning do to improve the existing living conditions in Aliganj? (Explore in depth: open spaces, paved roads, sewage, water, electricity). 52 Annexure V Typical layout of a one-room tenanted house in Aliganj 53 Annexure VI List of key informants and dates of interviews Date Meeting June 14, 2012 Prof. KT Ravindran (Retired, SPA) June 21, 2012 Dr. Mayank Mathur (SPA) June 29, 2012 UNICEF Health Sector: Dr. Pavitra Mohan Dr. Jagadeesan Dr. Vinod Anand July 9, 2012 Sunil Mehra (MCD) July 12, 2012 Workshop with urban planners and health experts, held at UNICEF: Prof. KT Ravindran Dr. Mayank Mathur Kanak Tiwari (IUDI) Sanjay Kanvinde (IUDI) Ranjit Mitra (IUDI) Dr. Rabidyuti Biswas (SPA) Vinod Dhar (DDA, IUDI) Dr. Srihari Duta (UNICEF) July 16, 2012 Prof. Kavas Kapadia (SPA) July 17, 2012 Prof. Rajiv Kadam (CEPT) July 18, 2012 Kirtee Shah (ASAG) July 18, 2012 Manvita Baradi (UMC) 54 Annexure VII Illustration of key issues of analysis (Based on the information collated from desk review, FGD, and key informants 55 Background Note on Internship Programme Knowledge Community on Children in India (KCCI) initiative aims to enhance knowledge management and sharing on policies and programmes related to children in India. Conceived as part of KCCI, the objectives of the 2011 Summer Internship Programme were to give young graduate students from across the world the opportunity to gain field-level experience of and exposure to the challenges and issues facing development work in India today. UNICEF India hosted 40 young interns from Australia, Canada, Colombia, Germany, Greece, India, Korea, United Kingdom and United States of America to participate in the 2011 Summer Internship Programme. Interns were grouped into teams of four or five and placed in 10 different research institutions across 8 states (Andhra Pradesh, Gujarat, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, New Delhi and Orissa) studying field-level interventions for children from 25 May to 3 August 2012. Under the supervision of partner research institutions, the interns conducted a combination of desk research and fieldwork, the end result of which were 11 documentations around best practices and lessons learnt aimed at promoting the rights of children and their development. The case studies cover key sectors linked to children and development in India, and address important policy issues for children in the country few being primary education, reproductive child health, empowerment of adolescent girls and water and sanitation. Another unique feature of this programme was the composition of the research teams comprising interns with mutlidisciplinary academic skills and multicultural backgrounds. Teams were encouraged to pool their skills and knowledge prior to the fieldwork period and devise a workplan that allowed each team member an equal role in developing the case study. Group work and cooperation were key elements in the production of outputs, and all of this is evident in the interesting and mutlifaceted narratives presented by these case studies on development in India. The 2011 KCCI Summer Internship Programme culminated in a final workshop, at which all teams of interns presented their case studies for a discussion on broader issues relating to improvements in service delivery for every child in the country. This series of documentations aims to disseminate this research to a wider audience and to provide valuable contributions to KCCI’s overall knowledge base.