Internationales Asienforum, Vol. 43 (2012), No. 1–2, pp. 7–11 Urban Health in South Asia Case Studies from India and Bangladesh V. S. SARAVANAN / PATRICK SAKDAPOLRAK / CARSTEN BUTSCH Guest Editors Global society is currently witnessing a transformation of historic dimensions. For the first time in the history of mankind more than half the world’s population live in cities. The process of urbanisation is transforming societies and physical landscapes worldwide. Hence, urbanisation is one of the most powerful forces that humankind is currently imposing on our planet. This transformation has profound impacts on the health of people living in urban areas. In developing countries, large sections of the urban population do not benefit from the “urban advantage” of the better availability of health care. They are facing what has been labelled as the “urban penalty”: deteriorating health status due to inadequate access to basic infrastructure, or exposure to worsening environmental pollution. Additionally, the urban lifestyle of the growing middle class creates new health risks, such as diabetes and cardiovascular conditions. Against the background of these processes, the nexus of health and city has recently attracted the attention of researchers in various disciplines. The research ranges from descriptive approaches focusing on different determinants of urban health (e.g. Galea et al. 2005; Butsch et al. in this volume) to analytical ones aiming at the analysis of differentiated health vulnerabilities in urban areas (e.g. Sakdapolrak 2010; Mohapatra in this volume). Even though urbanisation in South Asia is comparatively low compared to other parts of the world such as East Asia, the urbanisation process is currently accelerating. Urban health in South Asia is much more complex than its counterpart, rural health. The rapid growth of a highly dense urban population in congested environments confronts public health with extreme challenges. Inadequate regional planning, inadequate regulation of water, air and soil pollution, poor hygiene, socio-economic polarisation of urban populations, severe deficiencies in urban health systems, and increasing poverty and exclusion, are some of the factors challenging urban health. Urban health is a low priority in most South Asian countries, where policies focus more on rural health. There is hardly any credible data available on 8 V.S. Saravanan / Patrick Sakdapolrak / Carsten Butsch urban health that could help in effective urban health care planning. Many of the urban poor who are especially vulnerable to health threats live in slums that are illegal and are therefore often overlooked by officials. Instead, the private health care sector mostly meets the needs of the urban middle and upper classes (Butsch 2011). This sector is often unregulated and cannot comply with acceptable treatment guidelines. While a few Asian countries have invested successfully in women and child development programmes that strengthen antenatal and postnatal care as well as improving nutritional services, very few health programmes show a measurable impact. Urban health involves a complex set of factors affecting health status as well as health care, a web which is not yet adequately understood. The collection of papers in this special issue highlights these concerns in the case of urban regions in South Asia. The papers were presented in a special session on ‘Human health in urban and peri-urban South Asia’ at the 21st European Conference on Modern South Asian Studies held from 26 to 29 July 2010 in Bonn, Germany. Drawing from examples in India and Bangladesh, the collection addresses the following questions: how does the urban context affect the health of urban dwellers in South Asia? What is responsible for the disparities in health status between the urban poor and the urban rich? Which strategies can different groups adopt when seeking health care? What makes specific groups of people in particular socio-ecological environments vulnerable to health threats? How can their health vulnerability be conceptualised, measured and analysed? What are the future scenarios for health vulnerability in a rapidly urbanising South Asia? The paper by Carsten Butsch, Patrick Sakdapolrak and V.S. Saravanan provides an overview of the urban health situation in India. As urbanisation rapidly proceeds the authors show that India’s population will become predominantly urban in the next 35 years. This paper identifies problems of urban health arising from social polarisation and analyses these impediments to India’s future development. In combination with shortfalls in planning and a lack of environmental regulation, there is a growing concern that half of India’s population will soon be living in poor environmental conditions, exposing them to various health threats. The authors express their concern that while these conditions affect the urban population as a whole, it is the urban poor who will be most exposed to these threats, as they live in illegal settlements with poor infrastructure and lack the means to cope with ill health. Accordingly, their access to health care services is often inadequate, thus resulting in a “medical poverty trap”. In his paper Vishal Narain concentrates on the growing use of wastewater in urban India. In particular, he highlights the policies and institutions that determine the mismanagement of urban domestic and industrial water Urban Health in South Asia 9 and its usage in peri-urban settings. He argues that peri-urban residents often live in “unorganized areas” that lack formal tenure status, depriving them of access to official sources of drinking water. These people tend to depend on illegal or semi-legal sources of groundwater, using hand pumps and tube wells. This leads to the acquisition of land by private entrepreneurs who control and provide water. This water is often contaminated and supplied without any treatment. The situation is getting more complicated with the disposal of untreated urban wastewater. In spite of being a severe health threat, it is valued by peri-urban agriculturists whose (agricultural) products are in high demand in the urban market. These dangers are increasing due to regulations which demand the relocation of factories to peri-urban settings. These factories threaten the peri-urban population who consider them a threat. All these developments pose health risks, such as skin diseases, tuberculosis and asthma. Saswata Ghosh and Srimoyee Bose examine health threats and increasing health disparities among children in urban India using the National Family Health Survey (NFHS)-3. In line with Butsch, Sakdapolrak and Saravanan, they demonstrate the growing vulnerability of poor children to health threats. In their analysis they show that children belonging to lower income strata suffer from acute and chronic diseases more often than the middle and the upper quintile of the population. Furthermore, children of illiterate mothers show a high prevalence of anaemia and stunted growth. This analysis reveals a strong connection between lower standards of living and health risks among urban children in the country. M.M.H. Khan, Oliver Grübner and Alexander Krämer focus on the difficulties in accessing health care faced by the poorer sections of society in Dhaka. The authors identify several factors that influence access to health services. These include socio-demographic and economic factors, cultural beliefs and practices, gender discrimination, geographical location, environmental conditions, severity of diseases, and political factors, as well as aspects related to the health care system. The authors reveal that not all types of health care providers are approached equally by slum dwellers. Pharmacies were identified as the predominant source of health care provision in the areas covered by the case study. These are followed by government hospitals, private practitioners with MBBS doctors, and private hospitals and clinics. Of the diverse factors which determine access to health care for slum dwellers, they identify the socio-economic and demographic background of the households as the main determinant for the preference of pharmacies for health care. To enquire into the vulnerability of the urban poor, Subhakanta Mohapatra proposes a composite indicator which operates at the household level. 10 V.S. Saravanan / Patrick Sakdapolrak / Carsten Butsch It comprises socio-economic status, environmental hygiene, the household’s mobility and the access of its members to health services. This analysis reveals that several interconnected factors influence health disparities in the case study area. The absence of effective response mechanisms to health problems on the part of the urban poor is closely related to an inadequate health infrastructure. Disparities exist due to the lack of coordination among development agencies and of community participation. They are also a result of the lack of reliable health data, which should form the basis for sound planning. In essence, Mohapatra calls for a shift from illness towards a focus on health that concentrates on the well-being of individuals. T.Vasantha Kumaran et al. investigate the ability of the urban poor to improve their health. Drawing on their long-term experience in a Chennai slum, the authors describe community-based approaches to resolve health problems on a micro scale, including health care issues. During their engagement with the slum community the authors were able to observe several instances of creatively solving health problems. This truly participatory research project constitutes a “best-practice” experiment for in situ improvements – fuelled by external advice without paternalism. It proves that socially inclusive development is possible, although this consensual and discursive process takes much more time than the “one-size-fits-all” solution. In her review of health policies in India Elvira Graner adopts an institutional theory approach. She analyses which stakeholders are involved in shaping health policies at various levels, ranging from the global to the local, and she describes the various reform approaches that have been adopted by different actors. She also includes critical assessments of recent developments. In her concluding remarks she proposes a research agenda for the implementation of policy guidelines. If the politically motivated promises of the last decades were to be implemented, she argues, not only the MDGs could be met but basic human rights would also be safeguarded. Collectively, the papers in this special issue emphasise the diverse factors influencing urban health in India and Bangladesh not succumbing to a linear one-dimensional ‘cause-effect-remedy’ perspective to addressing growing health threats in South Asia (Saravanan et al. 2011). All the papers highlight the fact that transformation processes in the course of urbanisation have profound implications for human health, especially in the case of the urban poor. Despite the many negative aspects regarding health and health services in the region, there are ample opportunities in South Asia’s cities. Due to the concentration of a diverse population and their wide-ranging socio-economic capabilities, better environments and better health systems could be realised at relatively low cost. However, unorganised urban growth, poor regulation of eco-system services, growing economic disparities, dif- Urban Health in South Asia 11 ficulties in securing adequate health care and inadequate coordination among development agencies, result in negative effects on health. This collection of papers analyses these shortfalls and underlines the increasing urgency for a better understanding of the complex set of interrelated factors affecting urban health in order to meet the needs of future generations. We would like to thank all who were involved in the publication of this special issue of Internationales Asienforum, the editorial board, the anonymus reviewers, and Pierre Gottschlich (Rostock) and Angela Herrmann (Freiburg). Without their support, criticism and encouragement this special issue would not have been possible. References Butsch, C. (2011). Zugang zu Gesundheitsdienstleistungen: Barrieren und Anreize in Pune, Indien. Stuttgart: Franz Steiner Verlag. Butsch, C., Sakdapolrak, P. & V.S. Saravanan (2012). Urban Health in India, Internationales Asienforum, Vol. 43, No. 1–2, pp. 13–32. Galea, S., Freudenberg, N. & D. Vlahov (2005). Cities and Population Health, Social Science & Medicine, Vol. 60, No. 5, pp. 1017–1033. Mohapatra, S. (2012). Assessing Differential Health Vulnerability of the Slums in Chandigarh, India, Internationales Asienforum, Vol. 43, No. 1–2, pp. 81–98. Sakdapolrak, P. (2010). Orte und Räume der Health Vulnerability: Bourdieus Theorie der Praxis für die Analyse von Krankheit und Gesundheit in megaurbanen Slums von Chennai, Südindien. Saarbrücken: Verlag für Entwicklungspolitik. Saravanan, V.S., P.P. Mollinga & J.J. Bogardi (2011). Global Change, Wastewater and Health in Fast Growing Economies, Current Opinion of Environmental Sustainability, Vol. 3, No. 4, pp. 461–466.