Recognition is famously a passage from ignorance to knowledge” said Amitav Ghosh in The Great Derangement, his recent meditation on how literature has engaged with climate change and its effects. Ghosh laments the absence of substantive engagement by contemporary arts and literature on climate change.
One does not have to look too far to see parallels of this neglect. Quick on the heels of the cheer brought about by the announcement of “average to normal monsoon” this year, was the news of heavy rains lashing Bengaluru, Mumbai, Chennai and other cities. Very soon, the news stories of the drought-like conditions and receding groundwater in and around Bengaluru were replaced with stories of waterlogging, overflowing waterbodies and mixing of sewerage water with rainwater. From smaller cities like Kalaburgi, there were stories of hospital wards knee-deep in sewage-mixed rainwater.
The monsoon system of rains is an ancient one; they have been observed and celebrated for thousands of years in our traditional knowledge, songs and literature, much before modern science discovered tools to predict them. Despite that, year after year, our cities reel under the effects of rains and the impending infectious diseases -- as if these are entirely unpredictable natural disasters. This begs the question if these are purely natural phenomena that we ought to cope with, or if mismanagement of city health and sanitation systems makes it a man-made crisis.
Rise of infectious diseases
Predictably, the heavy downpours tested the limits of drainage and solid waste management systems across India’s major cities. It is now routine to see heavy rain flush our solid waste into the streets and around our homes. Overlapping with the monsoons is the spike in the incidence of various vector-borne diseases like malaria, dengue, chikungunya as well as diarrhoeal diseases, especially in children. Dengue cases in the cities are on the rise with over 3000 being reported in Bengaluru alone this season. Diarrhoea is the third most common cause of death of children under five in India.
According to an estimate by the Million Death Study group, up to 300,000 children die every year of diarrhoeal disease, a largely treatable and preventable health problem that most countries in our region have addressed better. In fact, a study assessing the Global Disease Burden, published earlier this month in the international medical journal Lancet, ranked India 126 out of 188 countries in meeting the United Nations Sustainable Development Goals by 2030. Among the important drivers of India’s poor score is, unsurprisingly, our drinking water and sanitation system.
Hygiene and safe water
The strong link between public health and access to safe water and sanitation is an old story in modern medical and public health literature. In a poll conducted by the British Medical Journal in 2007, the sanitary revolution was hailed as the biggest medical advance since the first publication of the reputed journal in 1840, bigger than the discovery of vaccines, antibiotics and new medical and surgical techniques. Even today, medical students learn about the English doctor John Snow who, in 1854, analysed Cholera deaths in London and rightly attributed them to polluted drinking water. In a society where the bacterial cause of Cholera was not yet known, John Snow’s work built the foundation for public health. Earlier still, evidence of a systematic use of sanitation several thousand years ago in cities of the Indus Valley civilisation tells us how important the management of drinking water and sanitation is at the city level.
Emerging disaster
India’s push for a global centre-stage has produced cities with aspirations toward becoming economic and industrial hubs. However, in our zeal to jump onto the economic bandwagon, the foundational aspects of healthy cities have been forgotten. Cities are literally sweeping their dirt under themselves. Overflowing drains, lakes spewing out toxic froth and foam, free-ranging dogs and rats fighting over unsegregated wet and dry waste in plastic bags are the new normal in our cities. And most of us have learned to cope by simply looking away. Global health experts have called urbanisation the “emerging humanitarian disaster”. Our cities are not able to manage basic amenities for their residents, thus pre-disposing many in the cities to various infectious and non-infectious diseases.
Worse, the ill-effects of urbanisation are not equal. There is an unfairness about who bears the brunt of the city’s mismanagement. People living in poor neighbourhoods, the migrant workers from drought-prone areas coming in as cheap labour to build our metros and schools, and various other communities facing disadvantage either due to homelessness, disability, caste or gender are the most vulnerable to the effects of adverse weather and its resulting public health effects. With limited safeguards either in our health system or in our social security cover, the effects of dengue or chikungunya over migrant labourer families are very different from their effects on a software engineer or a doctor. Living in a health system where treatment for these illnesses are based on payments at the point of service delivery (in the private sector) or faced with poorer quality care in an under-resourced government health service, the poor are at a disadvantage. What is merely a bad traffic hour for one family is a house under water or a child faced with financially catastrophic hospital admission for another.
Protecting public health
Public health in cities cannot be wished away to doctors or health workers. Protecting public health involves an active engagement of the city municipal administration in disease surveillance, preventing disease and promoting health. And in doing so, we ought to strive for systems that work for all, not for only some. Posh neighbourhoods have regular cleaning and municipal workers in clean uniforms, whereas urban poor neighbourhoods are themselves dumping grounds for unsegregated garbage, further disadvantaging such neighbourhoods. Striving for reforms in municipal workforce so that sanitation workers have access to health, safety and a dignified working environment is still a far cry. Parks and public spaces are spick and span for evening walkers and yoga enthusiasts in some areas, as if these are merely middle-class pre-occupations.
We need city administrations to recognise the public health disaster on which cities are sitting. We need to recognise the problem at various levels. Firstly, at the level of city governance, wherein urban planning ought to incorporate the principle of equity in allocating resources and executing projects. Rather than pet projects in some neighbourhoods, city municipal corporations have to urgently fix our broken sewerage systems and invest in building up a capable municipal workforce. Secondly, greater consultation and participation of residents through ward-level engagement in tackling the garbage problem locally, and thirdly, a strengthening of urban health through greater engagement of public health professionals in urban planning, disease surveillance and strengthening urban primary healthcare systems is the need of the hour.
The history of natural disasters has shown that individual people and societies have resilience. Collective human history has often coped with disasters of global proportions. But for that, we have to act before we cross a threshold beyond which the situation may be irretrievable. And we are fast approaching that threshold in India’s cities. If we do not recognise the mismanagement of our cities as an important underlying cause driving poor public health and merely choose to deal with these as an act of nature, then our blindness is one that we have chosen.
(The writer is a public health researcher at the Institute of Public Health, Bengaluru)
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