What Transition Means for India’s City Poor

Each Indian city has two parts: one half lives in relatively clean and healthy environs while the other lives in congested and overcrowded slums sans basic amenities.¹

The British actor Sanjeev Bhaskar has recently been revisiting his family roots in the Indian subcontinent and also noting the huge contrasts with high-rise prosperity jostling for position with urban slums.² Indeed, anyone who has toured India other than by insulated dashes from one five-star hotel to another in a blacked-out limousine will be troubled by the poverty. India, a country usually said to be in transition but already an important global economic power, is still predominantly rural, for the moment anyway, with high rates of both urban and rural poverty. The world as a whole has reached the significant milestone of having half of its population as urban dwellers.³ Five billion people worldwide are predicted to live in urban areas by 2030 if current trends continue and by that same year India may have 576 million city dwellers, which is 45% more than today’s figure and will almost certainly take the country past the 50/50 milestone.⁴

By no means all of India’s economic growth is attributable to manufacturing industries but (as in the People’s Republic of China) there are concerns that environmental deterioration and its consequences may be part of the price to be paid for financial success. The city of Vadodara, in Gujarat State, has seen a tripling of its population to 1.5 million over the past three decades, an expansion of its chemical industry, and an influx of migrants leading to a fivefold increase in the number of slum colonies. Prof. Jayasree De, a geographer at the University of Baroda (the city’s former name), has summarized the risks of an urban environment that can deteriorate under the pressures of development. For example, anopheles mosquitoes are now finding plentiful breeding sites, and falciparum malaria accounts, extraordinarily, for 70% of cases of infectious disease.⁵ Impregnated bednets may be of proven value but the assumption is that users are in a recognizable home, and many of India’s urban poor are not. A subgroup lives in slums. Just how many do so is open to debate and census data may not paint a true picture. The New Delhi-based Urban Health Resource Centre (UHRC) has a project in Agra where it estimates that 50% of the city’s population are slum dwellers; the 2001 census figure was about 10%.⁶ In Indore and Meerut, the proportions were 33% and 44%, respectively. Countrywide, the total could be 100 million, more than the population of any European country—and that number is rising with one prediction forecasting 200 million by 2020.⁷

Economic transition usually brings in its wake a shift in illness patterns, from the infectious to the noncommunicable (e.g., cardiovascular disease and diabetes). Data in De’s article support that trend but the picture in an increasingly urban India is not yet clear. As De notes, safe drinking water and sanitation remain public health issues.⁵ A recently published study of infant deaths in the southern city of Vellore revealed that over the period 1995–2003 (when the infant mortality rate was 37.9 per 1,000 live births) 43% of all postneonatal deaths were because of diarrhea-associated illnesses.⁸ Prospering Indians may be starting to experience “western” diseases; for the urban poor, the threats to health appear more traditional.

Bhaskar² sees the country’s ability to absorb change, be it foreign invaders or today’s technology, as a strength, which indeed it is. However, it is not at all clear how India’s newfound prosperity will be absorbed to the benefit of its urban (or indeed, rural) poor. The UHRC, working with partner organizations such as the U.S. Agency for International Development and local nongovernmental organizations, is piloting health projects in the abovementioned three cities, and the concept of private–public partnership—a concept that is not without its critics—features strongly. Time will show what contribution these ideas can make but it should not be forgotten that India’s slum-dwellers, via poorly rewarded service jobs such as street cleaning, are helping to keep cities habitable for the better-off. They are contributing to the urban economy too.

Kenya is the site of something very similar to India’s UHRC. The African Population and Health Research Center’s Nairobi Urban Health and Poverty Project (NUHPP)⁹ is a long-term study asking questions that will be recognized in cities everywhere—namely, is it better to reform health care delivery or to improve people’s livelihoods, or both? From a pooling of the experiences of initiatives such as the Indian and Kenyan ones, there might emerge a consensus on evidence-based best practice. Who better to manage that pooling than the International Society for Urban Health?