Of rainy cities and public health

This is an expanded version of an article published in Sunday Spotlight submission to Deccan Herald dated September 17, 2017

Recognition is famously a passage from ignorance to knowledge

The above line is from Amitav Ghosh’s 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 Bangalore, Mumbai, Chennai and other cities. Very soon, the news stories of the drought-like conditions and receding groundwater in Bangalore 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 sewerage-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 the city health and sanitation systems makes it a human crisis.

Screen Shot 2017 09 19 at 10 14 29 AM

Rise of infectious diseases in cities

Predictably, the heavy downpours tested the limits of city drainage and solid waste management systems. 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 cities are on the rise with over 3000 being reported within Bangalore 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, every year die of diarrhoeal disease, a largely treatable and preventable health problem, that most countries in our region have addressed better. In fact, a study assessing 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.

Screen Shot 2017 09 19 at 10 16 30 AM
Based on reports generated for the National Vector-bourne diseases Control Programme. Possibly heavily under-reported; actual numbers likely to be much higher.
According to a projection, India may achieve only 2 of over 10 SDG targets by 2030 with our water & sanitation being among major contributors to this
According to a projection, India may achieve only 2 of over 10 SDG targets by 2030 with our water & sanitation being among major contributors to this. Map by GBD 2016 collaborators published in The Lancet 12 Sep 2017 under OpenAccess licence. See http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32336-X/fulltext

Hygiene and safe drinking water as a panacea

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 about the English doctor John Snow who, in 1854 analysed Cholera deaths in London and rightly attributed it to polluted drinking water. In a society where bacterial cause of Cholera was not yet known, John Snow’s work built the foundation for public health (See London School’s celebration of his bicentenary here). Earlier still, evidence of a systematic use of sanitation several thousand years ago in cities of the Indus valley tells us how important the management of drinking water and sanitation is at the city level (see archaeologist, R S Bisht’s presentation on Harappan hydro-engineering and water management).

Urbanisation as an emerging humanitarian 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 a new normal in cities; most of us have learned to cope by looking away. Global health experts have called urbanisation as an 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 diseases.

The irony is that 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 our urban 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 family are very different from its 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 as a city’s responsibility

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 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 and corporators to recognise the public health disaster on which cities are sitting upon. 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 and partnering with residents 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 health care systems is the need of the hour.

History of natural disasters and their devastation has shown that individual people and even societies have enormous resilience. Collective human history has often coped with disasters of global proportions. If we do not recognise and accept 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.


Additional facts and figures compiled by the DH team can be seen on the e-paper version of the article
Additional facts and figures compiled by the DH team can be seen on the e-paper version of the article


2 responses to “Of rainy cities and public health”

  1. Great article and very pertinent. I’m interested in the environment — health connection: would it be fair to say that even if governance is focused on public health per se, remedies are likely to have spin off benefits for (or will require direct focus on) the improving environmental conditions?

    1. Hey, thanks for sotpping by and reading. I strongly feel that many of these differences are merely because of the way we have put hard boundries between disciplienes (in academia) and even more impenetrables boundries across departments (in how ministries are organised). At a very practical level, some kind of inter-departmental/inter-sectoral engagement is much needed. One woudl imagine that such engagement is easier at city level (than for example at the federal/central level), but sadly, either due to lack of vision, or leadership (certainly not for lack of evidence), this is lacking. 🙁

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.