The Lives of the Urban, Migration and Malaria
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- The Lives of the Urban, Migration and Malaria
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Community Health Learning Programme
2009
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[Health Learning
Experience
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Community Health Learning Programme
May 2009 to August 2009
THE LIVES OF THE URBAN POOR, MIGRATION
AND MALARIA
Malavika Thirukode
Intern, Community Health Cell
ACKNOWLEDGEMENT
Participating in the Community Health Learning Programme has given me a valuable chance in
meeting with and helping individuals and organisations at the very heart of a community.
I would like to thank my professor Dr. Priyadarshini Maddi for having introduced me to the
Community Health Cell, my mentors Dr. Rakhal Gaitonde, Dr. R. Sukanya, and all at the
Community Health Cell for their constant support and encouragement towards making my time
spent in the programme productive.
My sincere gratitude to Lakshapati sir, Patil sir and Ramadevi of APSA for going the extra mile to
make sure my participation in their programmes was comfortable.
Also, heartfelt thanks to all my friends in CHLP for making the experience extra special and I wish
them good luck.
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Introduction
As an intern in the Community Health Learning Programme 1 spent time after orientation re
defining my learning objectives. These evolved with our collective experiences as a group as well
as some that were personal, which left me feeling 1 understood ‘society’ very little.
My initial learning objective was to understand better community participation in disease control
programmes. This soon became a need to understand the unheard in society, the ’migrants’,
‘constructions labourers’ and others, to listen and later ponder on what it means to live as they do in
the heart of cosmopolitan India. I also tried to gauge the status of their health and their awareness
about the same through the various opportunities CHLP and other organisations provided me. I
began with a few visits to urban health centres and dispensaries in and around Koramangala, later
proceeding to Association for Promoting Social Action (APSA) where I accompanied field staff in
their work with communities who live in the streets as well as in registered slums. As a beginning I
was encouraged to meet with two families in Koramangala who live on the streets. Additionally I
also read some material on the link between migration and Malaria as well as some examples of
community participation in control programmes of the same. I found my time as an intern very
enriching and self-engaging.
In the report I would like to describe the sights, responses, thoughts and questions that both engaged
pre-conceived notions and gave me a peek into migration, the urban poor - their quality of life and
their needs, the role of community workers, both in areas that are provided guidance by NGOs and
in those where there is no such initiative. Also, 1 have included brief summaries about the reading I
was able to do during the course of the programme.
The First Step
I began by introducing myself to two families who live on the streets in Koramangala. The nail
biting first steps led me to individuals and families who were very welcoming and helpful. My
preconceived notions that they might be suspicious of me or scared or rude or even dangerous to
introduce oneself to was now affirmatively broken. Both families have migrated to Bangalore in
search of work, one from West Bengal and the other from Raichur, Karnataka. Below is a brief on
my time spent with them.
Family One: Geetha is from Kolkata_and has lived in Bangalore for the past three years. They are a
family of four- herself, her husband and her two sons. She lives with her husband and younger son
in Bangalore. Her son, Babu, is eight years old and does not go to school, as he is unable to speak
Kannada. In their village Babu used to go the village high school. Geetha works as a domestic help
in the nearby apartment complex and her husband is a construction labourer. They have left their
voter’s identity card and ration cards at home in Kolkata and have unsuccessfully asked for help their biggest obstacle being their unfamiliarity with the language. They seek care from a nearby
private practitioner and have earlier spent upto Rs.500 on such a visit. They lack supply of potable
water and sanitation facilities. They suffered a recent bout of Chicken Pox that they attributed to the
nearby sewage.
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Family Two: Later I spoke with Lakshmi whose family hails from Raichur. They arc a family of ten
and have come to Bangalore as labourers who lay the roads. None of the children go to school and
they have left behind their voter’s ids at home and do not have ration cards. They live under plastic
sheets and lack basic water and sanitation facilities. The community is not visited by any social
worker - government or private. Lakshmi did not know where the nearest hospital is in the area.
Owing to my limited fluency in Kannada 1 was unable to understand her health problems except for
that they suffered from joint pains frequently.
I also visited two urban health centres and one urban health dispensary.
Audogodi Health Centre: At the Audogodi Health Centre (HC) I spoke to the nurse about the
general activities conducted by her and the services available. At the HC routine ANC and PNC
checkups, blood investigations (Hb, sugar, VDLR), urine (routine) are referred and immunizations
are carried out. Blood and urine investigations are earned out in the nearby Wilson Garden and
Siddiah hospitals. The nurse goes on house visits and conducts awareness meetings on sanitation
and the national programmes at the nearby schools, sabhas and temples.
Some of the camps carried out by the HC are:
1. School Health.
2. Outreach immunization.
3. Encouraging male participation.
4. Adolescent programmes.
5. Audiovisuals
The fixed programmes in the HC are:
1. ANC and PNC, Monday and Friday
2. Immunisation, Thursday
3. IUD-OP-_CC, daily
4. Well Woman Clinic, Tuesday
Charges:
1. Lab-Rs. 100
2. OPD-Rs.5
3. Anti Rabies injection- Rs. 100
The HC is a well-made building with a large compound.
Audogodi Dispensary: The Audogodi Dispensary has a dental as well as a formal clinic and a
DOTS center. Apart from the DOTS center, the consultation room and the dental clinic (run by the
Bangalore Dental Science College) it also has an additional room with one stretcher and a common
bathroom. There is a chart of available medicines and the count of various ailments reported at this
dispensary. From the information on the chart I inferred that the area suffers from high incidence of
Diarrhea and Enteritis (more than 70 cases), skin diseases, urinary tract infections, dog bites and
other respiratory diseases. Mosquito borne diseases is not a problem in this area of Bangalore and
the most prevalent cases based on the experience of the medical officer present were Diabetes,
Hypertension, fevers owing to urinary tract infections and wounds.
Madiwala Health Centre and Dispensary: The Madiwala Health Centre and Dispensary also has a
DOTS centre and a birth and death registration office.
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Interaction with Street and Slain Communities
CHLP directed me towards meeting organisations and people involved in related work. 1 was asked
to visit APSA and in doing so was given the opportunity to observe and learn from the very roots of
the organisation.
APSA works broadly with the urban poor in Bangalore and works to engage and empower the
community towards availing facilities they are rightfully entitled to, thereby helping them climb the
first steps in being self-sufficient and protected from exploitation. They run ‘Dream School’- a
bridging school to re-introduce children from varied backgrounds such as child labourers, school
dropouts, children who have been rescued from distress and migrant children to mainstream schools
as well as give them opportunities in vocational training that will eventually ensure them a safer
future.
After my first visit I was introduced to the director of APSA - Mr. Lakshapati and the chief field
coordinator - Mr.Ishwara Patil. Together I was able to chart a plan of action that would enable me
to visit communities, interact and observe focus group discussions (conducted by APSA field
coordinators and social researchers from the Indian Institute for Social and Economic Change) and
community resource mapping along with members of the community.
Focus Group Discussions
They were conducted in the following areas that lie along the length of Old Madras Road and
immediately behind the APSA premises. These were conducted with women and children
separately and in one instance men also attended the discussions. All the discussions conducted
covered broadly the following - Child Rights, Gender, Alcohol and Development.
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Ibutipura
Batralli
T C Pallya
Pai Layout
Ibutipura Women and children
Groups: Women (10) - some participants were from the self-help groups and some were not. Their
husbands later joined some of the women. Participants among the adults were drivers, construction
workers, domestic help and housewives. Children (4th, 6th and 9lh standards) from the nearby school
also participated.
As this was the first focus group discussion that I had attended, I paid greater attention to the
methodology rather than the group’s response to most questions.
Child Rights
• Questions asked and discussions thereafter pertained to identifying resources that are
accessed by children in the locality and their perceptions on children and their rights.
• The group was asked about the quality of the resources for their children.
• The children specific schemes provided to them, how many avail of them and how aware
they are of the schemes they are entitled to.
• Awareness and participation of parents in government forums such as the SDMC.
• The discussion tried to gauge the prevalence of child marriage, child labour, and cases of
missing children in the locality and understand the health of the children in the area.
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Reactions to the Above Discussion
• Quality of the mid day meal is poor.
• Most parents do not avail of educational schemes for their children although there was a
general understanding that schemes are specifically available for girl students and on the
basis of caste.
• One mother was disturbed by the fact that the education schemes that she was aware of were
directed to girls only.
Alcohol and Ghutka
• Questions in this section broadly covered the availability of alcohol in the locality (shops),
preferences (illicit liquor or otherwise), problems related to alcoholism - domestic violence
and addictions and their direct or indirect influence on children.
Reactions to the Above discussion
• Most participants (both women and children) were very open to the discussion.
• A few of the women responded - “Only those who drink will know where to get it.” This
could either be her discomfort in discussing the topic or due to her weaning interest to take
part in the same.
• All were in agreement that violence owing to alcohol was common in the community and
also that Ghutka usage is widely prevalent.
• On questioned about wine shops in the locality one response was interesting. One participant
mentioned “ a border area” that separated broadly the area where the Tamil speaking
families live from that in which the Kannada speaking families live, as a result of which they
were unable to let us know of the wine shops on the other side of the road. Does this imply
very little interaction between the two sides of the locality?
• As the women have little control over the family income some expressed an inability to
control their husband’s alcoholism.
APL/BPL/Labour Cards and Schemes
• The BPL system is being implemented well in the locality.
• The quality of rations is good.
• The store is good. However they do not get supplies over three days from the day the rations
are bought to the store.
• Those among the participants who work in construction are unaware of ‘Labour Cards’ and
its use.
• Some participants were aware of schemes like the ‘Bhagyalakshmi Scheme’ but chose not to
avail of them.
Utilities
• The waler supply in the locality is governed by politics.
• The local leader from the congress ensured them water supply, but the present leader who is
from the BJP has not, the common excuse being that there is ‘repair work’ in progress.
Police
• It was made clear to the group that having gone to a police station implied both going for
one’s own purpose as well as going on behalf of or accompanying someone.
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There is a common perception that one must go to a police station only in an instance ot
crime.
There is no reporting owing to fear of approaching the police.
Also those who have approached them have had experiences of shabby treatment where the
police have responded saying. “People from rented houses don’t deserve...”
Gender
• The response was that the husbands take decisions as they earn more than their wives.
• Wives only inform their husbands and do not discuss issues with their husbands.
• In the instance of the FDG, it was interesting to observe the men in the group (husbands
whose wives were also present) encouraged the women (not necessarily the wife herself) to
speak, take part and ask questions.
• Most of the children felt their father was superior to their mother due to his role in decision
making. Some of their responses were that, the father is the head of the family, they are big,
they are elder to them, and you must listen to them or else get beaten up.
• Some of the children agreed that in the locality girls are sent to government schools while
the boys are sent to private schools. They said that it is because girls will get married and
leave the family, hence the little importance to their education.
• All the girls agreed that this view is discriminatory.
FGD Co-Ordinators Response to the Children
• The opportunity to interact with the children was used to also create awareness amongst
them. In the context of gender roles in a family the FDG was taken advantage to emphasize
that respect for elders was good but respecting their role and that of their mother’s is also a
possibility and is also good to consider.
Groups in the Locality
• Sanghas are formed in the locality (by whom?) but their activities are not followed up on.
Migrants in the Community
• The adult participants had mentioned that there has been an influx of people from Bihar who
work mainly as construction labourers.
• The children listed out the following - Assam, Bihar, Orissa, Kerala and Tamil Nadu on the
basis of their classmates in school.
HIV- AIDS
• Adults as well as the children had nil awareness on HIV-AIDS
• Some of the women reacted negatively, which is suggestive of the issue being a taboo to
discuss.
• It is important to note that while the children had heard of HIV-AIDS, their knowledge of
how it spreads is very poor.
• The children believed that taking old medicines and mosquito bites cause HIV-AIDS.
• Some (very few) of the children said it spreads through blood.
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Treatment Seeking
• Everyone visits the private clinic in times of complications.
• They go to the nearby government hospital for pregnancy related issues and immunization.
• The services of the government hospital is good, they arc treated well and are not asked to
pay.
• Some of the participants said that a lot of money is spent on ‘Birth Registrations’, mostly
due to change of name at a later stage.
• They were unaware that birth registration in the first 25 days is free (token system).
• Some cases of infant mortality have occurred in the locality.
Batralli, Anganwadi
Groups Present: Children (11) - in the age group of 11 to 13 years.
Women (11) - Included the anganwadi
some of the children present.
helper
and
mothers
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Child Rights
• Both groups (children as well as the women) are aware of ‘who’ a child is with respect to
the definition based on the age of an individual.
• They are aware that children are entitled to basic rights but are unable to give examples of
‘what’ these rights are.
School
• The children are unaware of what they are entitled to as students of a government school.
Schools have toilet facilities with separate sections for boys and girls. They also have a
playground and a community hall. They do not have library facilities, either in a building or
mobile. Some of the mothers said that in the English medium schools the mandatory books
have not been given and there is no playground in the school.
• They have not heard of the School Development and Monitoring Committee (SDMC) and
do not know the functions of the same. Some of the women have attended meetings at their
children’s school where they were asked to sign papers. However, they are unaware of the
presence and purpose of the SDMC and are not clear as to whether the meetings they had
attended were pertaining to the same.
Midday Meal
• Children were happy with the quality of the meal.
• The mothers were very unhappy with the meal given in the school. They said the quality of
the rice used is very poor and there is no source of clean drinking water within the premises.
Some mothers also said that children do not complain and bring the food home so as not to
offend the teacher.
Teachers
• Children expressed satisfaction with their teachers.
• The mothers were very dissatisfied with the teachers and feel that there is an overall lack of
interest to teach among the teachers and they are careless.
• Some of the women have observed a teacher talking on the phone during class hours while
the children are ignored.
• Some of the mothers felt helpless to complain as they feel nothing will happen if they
singularly complain.
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They also expressed concern over the roads their children must take to reach school. The
roads arc major highways without pedestrian crossings or police patrols with traffic that is
mainly of trucks and intercity buses. As they fear for the safety of their children they
personally drop and pick them up from school.
Child Marriage
It is prevalent in the community. While the children are aware of one such case involving a child in
the age group of seven to eight years, the women were aware of three to four instances. The
children and women are aware that child marriages should not be the norm and reasons for the
same. Some women are also aware that it is an illegal practice.
Child Labour
There are a few children who work in the area. Both groups elicited the various jobs the children are
engaged in, construction workers, bus cleaners, garage workers, as workers in restaurants and as
domestic help. It was interesting to not that the children listed all of the above mentioned work.
Children’s Health
They have had instances of water borne illness such as Typhoid and Jaundice. All those present in
the discussion were immunized against Polio. None of the participants of the discussion prescribe to
home remedies. They go to Patil Hospital first and choose to go to the government hospital later.
They are happy with the treatment at both hospitals.
Alcohol, Ghutka and Illicit Liquor
• The children who took part in the discussion were very open to discussing the issue.
• Both groups are aware of liquor shops in the community and the preference is for bottled
liquor.
• Ghutka is also commonly used in the area. Children identified with ‘Pan Parag’ when issues
related to Ghutka usage were discussed.
• Both groups said that illicit liquor was available in the locality earlier but is unavailable
now.
• Usage of both alcohol and Ghutka is more among the men. Children are aware that Ghutka
usage will cause Cancer and that alcoholism contributes to domestic violence, some of the
children also know of such cases in the area. The children were of the opinion that alcohol
would affect one’s Kidneys, lead to blood loss and heart trouble.
• Children are also aware that people can overcome these addictions.
• Women in the discussion spoke more on the issue of domestic violence owing to alcoholism
and did not bring to attention health related problems owing to the same. The police have
conducted door-to-door campaigns urging people to give up the habit. There has not been
any other de addiction camp apart from this in the area and most people who have given up
the habit have done so on their own will and not as a result of outside intervention.
• Some women have enrolled their children with the help of the local social worker into
hostels in order to protect them from domestic violence owing to alcoholism.
APL and BPL Cards
• Both groups possess and are aware of the role and purpose of the cards.
• Most families own a BPL card.
• Both groups agreed that the quality of rations is poor and they have been cheated off the
exact quantity owed to them, according to the children by half a Kg. Women are aware of
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the units owed to them by the ration shop (1 person = 4Kg). They claim that there are
families who get more than twenty kilos of rations in the area.
Pension Cards - nobody in the locality has pension cards. Some had mentioned that those
who did were not getting the amount that is due to them.
Children and Women’s Groups
• Bosco and Kids - newly formed for the children, is only for boys.
• Girls do not have groups of their own.
• Sthree Shakti - Is very popular in the locality and most in number.
• Teachers Sangha - Sthree Shakti and the Teachers Sangha have organised immunization
programmes and doctors visits
• Ujeevani and Shishu Mandir are some of the other groups, which were discussed about.
Utilities
• Toilet and water facilities are of major concern to both groups. Both groups felt embarrassed
about discussing the issue.
• None of the houses in the locality have indoor bathrooms.
• Everyone has to use the banks of the lake, which all the women agreed was dangerous.
There have been reports of accidents involving children there.
• There have been instances where the sewage and drinking water have mixed leading to
water borne illnesses among the children.
• Water supply is usually at night and there is no payment for the supply.
• The locality has direct electricity supply.
• There are garbage collection dumps.
• They do not have a bore well in the area.
Police and Local Governance
• The police station is 11 km away in Hoskote.
• The children were of the opinion that the police take bribes. Some of the children have
visited a police station.
• Everybody is aware of their local leaders, Iranna and Nagesh Reddy (MP)
• Women are aware of the election process.
Domestic Relations
• Most of the children felt strongly that their father at home takes decisions.
• The children’s response was that their father ‘s income buys the household food and that he
is responsible for their school fees, books and for decisions on marriage.
• The mother of the family helps out in doing their homework.
• The children feel they do not get discriminated with respect to education.
HIV
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Children are not aware of what HIV and AIDS are.
Women were not aware either but agreed that having awareness about it would be helpful to
them.
Pai Layout Residents
Conducted by the Institute for Social and Economic Change (ISEC)
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A few observations:
• Seven members have ‘Pension Cards’ and 90% of the community has voters’ ids.
• Local leaders of any political party have never addressed their needs.
• Some members have lost employment owing to health problems and accidents. In the case
oi accidents, APSA has helped the community file cases and garner help from the legal
system.
• All the children go to the nearby ‘Tent School’
• Parents expressed a lack of accountability in the functioning of the school.
• They face water and sanitation problems.
• Some groups in the layout do not pay rent for the land they occupy while some others do.
• This group in Pai Layout has moved within the locality 2-3 times.
• A government health worker has never visited them.
• Some of the issues they would like to address are,
1. Organising Sanghas for both men and women.
2. Open savings accounts in a bank.
3. Gain access to drinking water.
4. Be given a permanent place of stay with facilities for a decent way of life (house,
water, toilets).
5. A good school for their children.
• Problems they feel hinder the organisation of a Sangha in the community,
1. Lack of money.
2. Lack of permanent residence.
3. Threats from landlords.
Observations - Methodology
• Always maintain respect for persons who are being discussed - no finger pointing.
• There were attempts to include everybody in the discussion by the more confident women,
men and the coordinator conducting the FGD.
• Participant’s answers to questions were tactfully used to understand their opinion on an issue
as well.
• Questions that seem ambiguous are explained through instances and examples.
• Always emphasize the context. In this case all questions pertained to Ibutipura/Batralli/Pai
Layout as a whole and not just the street they live in and the few houses to their right and
left.
• The group assembled must be representative of all households in the locality.
• The importance of finding a suitable place and time of the day.
• Maintain focus on point of discussion.
Observations - Learnings from the discussions attended - General
• Focus group discussions are an excellent tool to gain an overall understanding of the
utilities, needs, awareness and beliefs of the community. Also, it provides a platform to
build rapport and expand the work of the organization in the community keeping in mind
‘their’ needs.
• The definition of ‘Migration’ and what defines a ’Migrant’ became clearer. It became
apparent that within the limits of the city most families who are not from Karnataka have
lived in Bangalore for over fifteen to twenty years and gave assimilated into the local
population. Therefore, I found it difficult to categorize them. In the end I realized that in
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many different ways we are all migrants. My experiences therefore focused on learning
more about the urban poor.
Most families 1 was able to meet are form North Karnataka and Tamil Nadu. Some of the
individuals who participated in the FGDs and those who we spoke to individually had
mentioned that more recently there has also been an influx of people from Bihar in the same
locality.
The families belong to two broad categories. ‘Street families’, who live on the road under
plastic sheets on land that is not officially under the slum development board and ‘Slum
families’, who live in concrete and brick colonies that are officially registered with the slum
board.
The opportunity for better livelihood options in Bangalore spreads through word of mouth.
Travel expenses are covered by loans.
The reasons cited by the families for migration were many. Some of the most common
reasons cited are the following - Higher wages for the same kind of work in Bangalore
compared to their home towns and the failure of agriculture on their land owing to lack of
irrigation facilities.
Learnings Specific to Issues
Land
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Is a constant source of worry to those families who live on the street.
Some live on railway land. This gives them a degree of immunity against evictions by
private contractors and local leaders.
Others on the street but not on railway land reported paying a monthly rent to a local leader.
Families who reside in registered colonies are more secure on matters of shelter.
Most communities have developed on land that belongs to the lake authority.
While certain sections of the colony are registered, owing to expansion of the community
certain sections are left out, for purposes such as voter’s id. Also, this also poses safety risks
as these expansions occur on unsafe ground and in close proximity to the lake.
Governance
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In Pai Layout, T C Palya and Ibutipura, owing to the work of APSA all families have
Voter’s ID, Ration Cards, Labour Cards and Pension Cards.
With regards to the community’s interaction with their local leaders, all members of the
community practice their franchise but there remains a lack of interest on the part of the
leaders after election season.
For instance in Pai Layout, the local leader ‘Cement Nagarajan’ is a mere signature on
Pension Cards. Such needs (signatures and stamps) are the only instances of ‘interaction’
between the community and their elected local representative.
In T C Palya, the local leader is an active land mafia member. Hence APSA coordinators
maintain a healthy distance and have introduced only a few members of this community to
him so as to reduce the risk of eviction, as they do not have the security of government land.
Health
A health worker has visited none of the communities.
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Maternal Health - Most mothers arc prompt with regard to their checkup however chose to
deliver at home with the help of a midwife (an elderly woman).
Most illnesses are owing to ‘water borne’ diseases like Jaundice and Cholera and respiratory
problems.
There have been cases of the entire community falling ill during a particular rainy season
such as an instance in Pai Layout. As the cases were not recorded and were described as
being fever, vomiting, diarrhea, body aches and chills 1 presume it might be owing to both
water borne as well as mosquito borne illness.
All areas visited lacked access to basic geriatric care and de-addiction opportunities.
The only immunization mentioned was that of ‘Polio’. None other was mentioned during the
FGDs.
Treatment Seeking
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Most on the street visited the hospital when their children were taken ill whereas this seemed
not the case when an adult felt ill, in which case care would be sought if it hindered their
ability to work.
Private clinics were everybody’s first option. Some also go to the local pharmacist for a
diagnosis of their problem.
During the FDG in Pai Layout 1 asked them if it was absolutely necessary to get an injection
on a visit to the hospital. One participant explained that it is for the doctor to decide on its
necessity. Though it is not representative of what everybody in the group thought of the
question it was good to know that the issue which I had previously read to be a trend might
not be so anymore.
All participants were of the opinion that home remedies are inferior to allopathic medicines
in this time and age. The common response was that they do not alleviate illness today as
they did in yester years.
The community living in T C Palya believes that the sacrifice of a chicken and the use of its
blood is a good remedy to overcome illness. One of the children had mentioned that initially
someone who is ill is taken to the hospital and if the illness worsens they would sacrifice a
chicken.
Snakes, dogs and mosquitoes are a major nuisance.
Preventive Measures
All communities use mosquito coils. None mentioned the use of bed nets. Some individuals
complained of irritation to the eyes and skin owing to the use of coils (allergies).
School
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All areas have a government primary school.
Mid-day Meals, while most children said they liked the meal, adults were unanimously
dissatisfied with the quality of the meal.
Some of the schools lacked drinking water facilities.
Most schools have separate toilet facilities. However, the school at Batralli lacked such a
facility. Children need to use the banks of the lake, which poses a serious safety threat and
has resulted in accidents.
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Both parents and children arc unaware of the School Development Monitoring Committee.
Those who have attended meets at the school are unaware of whether they were in relation
to SDMC. This was due to the absence of an explanatory session with the parents and also
because some of the parents are illiterate and hence unaware of what it is that they are made
to sign.
Scholarships and books are given sporadically in all schools. There is not much awareness
on the scholarships children are entitled to.
Teaching is poor.
Housing
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In Pai Layout and T C Palya shelter is made of plastic sheets and some rods.
In Batralli and Ibutipura housing colonies were made of concrete and bricks.
Electricity and Water
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Families who live on the street buy water that costs a minimum of Rs.200 per month.
Families who live in the slums have good infrastructure such as bore wells and tanks.
However very few are in working condition. For instance in Ibutipura they have around six
bore wells among which only one works. Hence water is available only in the evenings and
is insufficient for their daily needs. The registered communities have had instances of
sewage and drinking water mixing.
Alcohol and Ghutka - Prevalence and Addiction
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There was no inhibition to talk about the issue.
Children and adults perceived the ill effects of alcohol and Ghutka abuse very differently.
However, both groups acknowledged that alcohol abuse was the leading cause of domestic
violence.
Women admitted to very little power over the family's income, which they felt to be the sole
reason in being unable to control their husband’s addiction.
In Batralli, women of certain households have enrolled their children in hostels with the help of
a social worker in order to protect them from domestic violence.
Children view alcoholism from a scientific point of view and most responses dealt with which
organs of the body alcohol affects.
Batralli and Ibutipura had problems relating to illicit liquor use previously but do not have this
problem now. Access to alcohol and Ghutka is very easy in the locality and known to all.
De-addiction in all areas was a result of the individual’s decision to do so and not due to any
intervention. The communities do not have intervention programmes in their area.
Gender Relations
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In all discussions the father was always quoted to be the superior.
Reasons for his superiority were many, for instance, he takes care of the school fees, books,
takes you out, decides on issues pertaining to marriage
‘Mothers look after the kitchen’ was a common answer among the children.
Among the adults, the women described themselves as being their husband’s informant. They
do not have the liberty to discuss the issue and partake in decision-making.
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Observations - Responses
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When discussing the issue of alcohol, one participant showed her disdain in talking about it
and said, “Only those who drink will know where to buy alcohol.”
When the topic of HIV/A1DS was introduced one of the response among the women was, “It
is not present in people like us.”
When the children at Ibutipura were asked how one gets infected with HIV these were some
of the responses, “You get it by ingesting old tablets”, “You can infected by being bitten by
a mosquito”.
A father in Pai Layout on being asked why the school his daughter attends is not improved
said, “We are poor. Our children go to school that is attended by children of other poor
families. Since all of us poor nobody cares.” (Accountability only to the rich?)
When he was asked about what he would like for the future he said, “We live for today and
my concern is whether I can survive today. I do not think about the future.”
Lecture at NIAS
There are two schools of thought regarding the definition of "Who is poor?"
1. Caused due to calamities that is both natural and man-made such as floods and political strife
(Jeffrey Sachs)
2. Caused due to the power struggles and red tape within society that discourage the socioeconomic
growth of the poor.
Prof.Banerjee proposes that the poor are well aware of their situation and limitations. They choose
to be where they are despite being aware of the opportunities in society. His study is yet to be
complete and the presentation was on his reflections from the data collected thus far. The field area
was Udaipur and parts of interior West Bengal.
Definitions of the poor - Very Poor (less than a dollar a day)
Poor (two dollars a day) and the middle class (between two and four dollars). The definition of the
poor as given by the World Bank and India's Planning Commission is the same.
The data collected covered food, assets and migration.
Food
They continue to spend on high cost low calorie food. They do not spend enough on food despite
having the ability to. (What if that is the only option available?)
Assets
Their sources of income are multiple and 95% of all those interviewed have land but lack business
assets and savings accounts. Most poor people are self-employed with small businesses.
The businesses run by the poor and the middle class are the same. In terms of numbers, the poor run
more businesses and the notion that most businesses are run by the middle class is questionable. The
difference is that the middle class are mostly salaried workers and begin business to keep members
of the family (wives starting tailoring units) occupied whereas the poor begin the same venture as
they do not have jobs and not out of choice. AU families spend heavily on health care. The number
of visits to a hospital per person is once in two months. However, despite these frequent visits
15
people in the communities studied die very early. It was suggested that this could be because of the
indiscriminate use of steroid injections and unethical prescriptions that could lead to resistance at a
later more desperate stage in life. People also insist on injections and drips. The worth of the doctor
depends on its use.
Migration in Search of Work
Is extreme!)' common but for very short periods of time, the maximum being for eighteen weeks.
Migration in this case is without the family. It is the largest source of income with most families
living on the earnings of four months for the rest of the year. Interestingly, owing to the hardships
of being a migrant worker people choose not to stay back and earn more. If growth continues in the
metropolitan cities, migration will reduce whereas if it is in the middle tier towns and cities,
migration will increase. There will soon be migration of entire families in this case, which will
positively affect education opportunities of their children.
Conclusion
People are aware of opportunities but choose not to take them owing to reasons of convenience.
While the poor begin business owing to a lack of jobs the middle class begin the same to "keep
themselves busy". In this context the poor despite a general lack of resources are more
entrepreneurial. Therefore they are neither victims of powers outside their control nor are they held
back by power struggles.
Inward Learning
The experience as a whole has allowed me a peek into the working of an organization with
communities that are both permanent as well as those that are nomadic. Participating in field
activities helped me explore parts of Bangalore city that are lesser known and communities that are
invisible to the common eye. I had first hand experience of the rapport shared by the organization
with the community. The activities that I was able to observe showed me the means to interact with
people so as to gain an understanding of their lives as well as well discuss and share awareness on
issues in a sensitive and non-offensive manner. In interacting with families on the road 1 was forced
to face my fears. At first I was unsure on how I must approach individuals and introduce myself.
My fellow interns helped me with a few pointers they had learnt from experience. 1 spoke with the
woman of the family first and introduced myself as a student, I was pleasantly surprised by their
willingness to talk to me without fear of who I might be. All families were very hospitable and the
memory of sitting on a road in the heart of Bangalore city will remain a very special one for me. On
reflection I came to realise that my ‘fear’ was a result of growing up in an environment that shunned
street families as those who are dangerous and better left alone. Challenging this mindset helped me
learn to cope with people’s views that were in conflict with mine. The CHLP has helped me face
inner and outer conflicts with greater maturity and responsibility. I remind myself to pay greater
attention to detail and be more proactive towards charting my learning. Though it was hard to
maintain, my daily dairy now makes for a good read into all that 1 was part of during my time with
CHLP.
Outward Learning
Communities on the street differ starkly from those who live in registered housing colonies in
distribution, shelter, employment, awareness and access. Families living on the street are often
found alone or in small pockets along main roads and railway lines. They are mostly construction
labourers from other parts of the state and the country. Some of the families had come to Bangalore
16
through the NREGA and have not returned home, instead they have found work and decided to
stay. Whereas, most families who reside in registered colonies work as teachers in government
schools, domestic help, drivers and as other skilled workers. They have better access to water and
sanitation facilities compared to families on the street who have to buy water as well as lack access
to sanitation facilities owing to a lack of public facilities. In field visits with APSA 1 saw valuable
infrastructure that was in disuse. While there are certain myths in health that both communities
believe in, all families were aware of and utilized their nearest health facility. Owing to their size
and the fact that most members were family or friends, families on the street had a stronger sense of
camaraderie than those who resided in colonies. In colonies, self- help groups played a crucial role
in keeping the community together with the concerned NGO in working towards overall
development. In both areas women played a dominant role in interacting with the NGO.
Looking Forward
From time spent in CHC and APSA I realised I would like to take part in initiatives that address the
issue of implementation. I need to pay closer attention to time management and learn to better
present my thoughts both orally as well as in writing. Practicality and the need to be so has been
emphasized through out the programme and is a skill 1 hope to implement in learning and working.
Reading
I. Beyond Biomedicine: The Challenges of Socio-Epidemiological Research, Dr. Ravi Narayan,
CHC, Bangalore, SirDorabji Tata Symposium Series
• Introduces the social paradigm i.e. a shift from a merely biomedical perspective to include
Socio-Epidemiology in the control and prevention of Malaria.
• Programmes must look into knowledge, attitude and practices of the community and
personnel in the control programme like doctors and other health care providers.
• Close attention to the following factors - migration, health impact studies on development
work, economics of Malaria (for instance the expense of using DDT and medicines), the
skill, competence and efficiency within the public health system, relevance of specific
control measures in the context of the way of life of the specific community, include
participation of sociologists and anthropologists in disease prevention and control
programmes.
• Research on new initiatives must be in the context of the ‘need’.
II. The Contextual Determinants of Malaria, Determinants of Malaria in South Asia, Vinod Prakash
Sharma
• “Sustainable Malaria control requires a primary attack on poverty, health system reforms,
emphasis on community based approaches and investments in research and development.”
• This chapter studies the following broadly, FORESTS, GEM MINING,
DEFORESTATION, POPULATION MIGRATION, IRRIGATION, URBAN AREAS,
INDUSTRIAL
AREAS,
INTERNATIONAL
BORDER
MALARIA
AND
SOCIOECONOMIC DETERMINANTS.
• Forests - There exists perennial malarial transmission owing to deforestation for
resettlement, agriculture, industries and the presence of streams. Tribals are most affected by
forest Malaria and hence are the most vulnerable population in this context.
• Gem Mining and Dam Construction - Facilitates the migration of non-immune populations
to work in malarious areas as well as migration of people from malaria endemic regions.
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Deforestation - Many examples enumerate on how deforestation and agricultural activities
help in the spread of Malaria owing to breeding areas that can be destroyed and kept in
check by the community. As different mosquitoes occupy different habitats, persons infected
owing to visits to the forest act as carriers.
Population Migration - The reason for migration being work and usually from areas with
high transmission. The chapter also mentions the gender bias in migration, i.e. men tend to
travel longer distances than women, hence facilitating transmission in the host population.
Irrigation - Leads to the spread of Malaria owing to increase in ground water levels coupled
with the lack of drainage in farms. Additionally due to the migration of labour from malaria
endemic regions.
Urban Areas - Malaria presence owing to artificial storage areas and the adaptability of
certain species of mosquitoes to breed in the new environment (Anopheles stephensi). For
the poor, reasons are poor sanitation and the rationing of water.
Industrial Areas - Examples showing the connection between construction of industries and
the prevalence of Malaria.
International Border - This is a relatively new ecotype and has resulted in the development
of numerous resistant strains. Facilitates transmission owing to lack of treatment facilities,
unscrupulous medical personnel, substandard medicines and unchecked movement.
Socioeconomic Determinants - Broadly , population movement (for work and political
strife) to urban areas with deplorable living conditions, malnutrition, medical expenses, lack
of access to medical facilities, practices such as plastering of mud walls over DDT sprayed
walls, insufficient and improper use of insecticides and anti-malarial tablets, difficulties in
sustaining community participation.
Examples of cost effective control in industrial areas and agricultural practices that can
control malaria have also been enumerated.
III. The Contextual Determinants of Malaria, Determinants of Malaria in South Asia, Population
Migration and Malaria, Janice Longstreth and Anatole Kondrachine
• The extent of Malaria within a population depends “on whether the receiving location is in
the developing/ developed world.”
• Covers the two basic types of migration - unidirectional and circular as well as the reasons
for migration.
• Explores the consequences for the receiving population especially since the major
population movements are to the developed countries where immunity is low. Immigrants in
developed countries live in substandard conditions and do not consider treatment owing to
problems such as language barriers and fear of deportation.
• Land use - For the purpose of agriculture which involves the introduction of non-immune
persons, new hosts and the possibility of drug resistance.
• Urban Construction - Provide various breeding opportunities such as excavation pits. Helps
increase malarial transmission owing to migration.
• As cities grow rapidly with inadequate or completely absent housing, the exposure to
mosquitoes and increased breeding sites increases the risk of transmission.
• Resettlement and development projects bring in labour, resulting in the formation of
squatters that lack cohesion owing to cultural and economic factors resulting in
overcrowding, lack of sanitation and hence ill health. This is explained in the context of
Ethiopian highlanders who were infected owing to their migration to the plains for irrigation
projects. Infection remains in the plains due to the nomadic movement of the pastoral tribes.
18
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Similarly reforestation activities in Brazil created opportunities amongst the non-immune
migratory population.
The chapter also highlights the link between occupation and Malaria. E.g. Migration of
nearly 60% of the population from the non-malarious hills to a malarious delta - Naya river
valley in Columbia.
The prevention and control of Malaria in developing countries depends on how efficiently
control programmes function and the immunity of the urban population to the new virulent
and drug resistant strains that are introduced by immigrants.
IV. Exposed and Vulnerable: Tribals and Malaria in Bihar, Malaria in India - Reflections,
Responses and the search for alternatives, Voluntary Health Association of India, New Delhi
Society for Community Health Awareness, Research and Action, Bangalore P A Chako S J and
Prabir Chatterjee
• The article covers the occurrence and the public health system’s response to the occurrence
of Malaria amongst two tribal groups - the Malto and the Santals in south Bihar.
• Malaria, especially Cerebral Malaria has had an extremely debilitating effect in the Malto
tribals. Their communities are located in a hilly belt and are not visited by health workers or
sprayers. Irrational practice among insufficiently trained personnel is rampant. This has
resulted in resistance in the community. The Malto tribals use herbal medicines for the
treatment of malarial fever and studies were being carried out by the Jeevodaya Dispensary
run by the Paharia Seva Samiti on the preventive aspects of the herbal medicines. Kala Azar
is also surfacing amongst the Malto tribe.
• The Santals are the third largest tribe in India. “Raban- rua” (cold fever) is how Malaria is
identified in Santali. Cerebral Malaria is referred to as “Bai” or “Mirgi” and is considered to
be different from “Raban-rua”. “Pila” refers to the enlarged spleen, is confused with Kala
Azar, which is also common in the community.
• The article brings out the cultural issues that need to be considered on confronting Malaria
in tribal communities. For instance DDT spraying is stopped by the Santals as it smells bad
and “Diku” (the non tribals) do not pay heed to sensitive tribal practices such as leaving
ones shoes outside the house before entering the house.
• Inadequacies in the health system, i.e. delayed functioning of labs, inadequate supply of
medicines for the population at risk and the inadequate supply of medical equipment. With
regard to preventive measures the lack of pesticide supply and the supply of expired
pesticides have been some of the stumbling blocks.
• Medications that are available and the manner in which they are prescribed have also been
detailed.
• Interestingly, the tribal form of governance has a worthy mention in the article which aides
in better understanding the sociological aspects to be considered when interacting with the
community in the context of Malaria.
V. Health of the Urban Poor, Prepared for the second national health assembly - Bhopal, Madhya
Pradesh
• “Studies conducted by NIN in Jabalpur and Calcutta showed a higher prevalence of
malnutrition among children in urban areas than the rural population.”
• Determinants of ill urban health area a result of poverty, malnutrition, overcrowding, lack of
water and sanitation, inadequate housing and insecure tenure of land.
19
The Jawaharlal Nehru Urban Renewal Mission aims at addressing and tackling issues of
sanitation housing to name a few but is prey to lobbyists and has imposed pre-conditions for
states to avail of the mission.
VI.
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Malaria and Migrant Labourers: Lessons from a South Indian Experience
This article enumerates on the steady rise in Malaria in Vellore, South India and the possible
role of the migrant diversity in the town complimenting the spread of the disease. This is
studied with the help of a case study that involves migrant construction workers, who came
to work in the CMCH campus, living in very poor conditions, had complained of fever and
were diagnosed with Malaria and Anemia.
Treatment had to end abruptly as they were sent back without notice to the authorities. The
facets discussed in the context of Malaria and migrants include,
1. Access to health care and their complete helplessness
2. They lived in conditions that were conducive to mosquito breeding
Malaria Transmission: Owing to the lack of health centres and access to health centres
leading to incomplete medicine regimes, migrants bring in Chloroquine resistant falciparum
injections to the existing community. Chloroquine resistant P.falciparum is common in the
areas from which the migrants come from.
Social and Ethical Issues: Migrants are completely dependent on the employer to seek
treatment.Stigma of an infectious disease may lead to them being moved out.
Will migration for sustenance be stopped in order to control infection?
Control on Migration Malaria - Violation of Human rights?: Screening for disease must be
the responsibility of the employer and bound by law. According to the National Malaria
Control Programme for Migrant Malaria, migrants must be encouraged to use bed nets,
allow spraying and use mosquito repellants. However, owing to the multiple
marginalizations of migrant families it remains to be seen as to whether they have the means
that is both inclusive and accessible. The socio-political scenario must also be tackled in the
context of Malaria keeping in mind that migrants are a high risk and vulnerable group.
VII. Malaria Control in Tribal Areas: Issues and Problems, Malaria in India: Reflections, Responses
and the search for alternatives.
• Malaria is a major problem in under five and pregnant women in Ganjam District (Orissa).
• The lack of information on treatment, guidelines to follow, lack of supply of drugs, lack of
trained personnel for injectable Chloroquine, lab facilities that are not upgraded and not
easily accessible.
VIII. ICMR Bulletin - The Epidemiology of Malaria in Orissa, June-July, 2006
Orissa - 50% of Malaria deaths in the country.
• Population Characteristics - 22.3% tribal.
• They live in the forests, forest-fringe and foothill areas. This leads to operational problems
leading to difficulties in accessibility.
• Population movements are due to the non-availability of work.
• Population movement led to the development of slums where there is an absence of
spraying, treatment of water receptacles along with movement of non-immune individuals.
• Socio-economic characteristics
* sj: * * * * * * * * * * * * *
20
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