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SWEPT UNDER:
A Study on the Health Status of Municipal Pourakarmikas (Solid
Waste Management Workers) in Bengaluru
Anusha Purushotham
A dissertation submitted in partial fulfilment of the requirements for the
Degree of Master of Public Health (MPH) in Social Epidemiology
School of Health Systems Studies
Tata Institute of Social Sciences
Mumbai
2019
DECLARATION
I, Anusha Purushotham, hereby declare that this dissertation entitled, “Swept Under: A Study on
the Health Status of Municipal Pourakarmikas (Solid Waste Management Workers) in
Bengaluru’’ is the outcome of my own study undertaken under the guidance of Dr. Harshad Thakur.
Professor, Centre for Public Health, School of Health Systems Studies, Tata Institute of Social
Sciences, Mumbai. It has not previously formed the basis for the award of any degree, diploma or
certificate of this or any other university. I have duly acknowledged all the sources used by me in the
preparation of this dissertation.
Date: 22nd February 2019
Anusha Purushotham
Master of Public Health in Social Epidemiology
School of Health Systems Studies
Tata Institute of Social Sciences
Mumbai
m i mi i! ill I
ii
CERTIFICATE
This is to certify thaffhe dissertation entitled “Swept Under: A Study on the Health Status
of Municipal Pourakarmikas (Solid Waste Management Workers) In Bengaluru” is the
record of the original work done by Anusha Purushotham under my guidance and
supervision. The results of the research presented in this dissertation/thesis have not
previously formed the basis for the award of any degree, diploma, or certificate of this
Institute or any other institute or university.
Date: 22nd February 2019
Dr. Harshad Thakur
MBBS, MD, DBM
Professor
Centre for Public Health
School of Health Systems Studies
Tata Institute of Social Sciences
Mumbai
iii
TABLE OF CONTENTS
1. Declaration
i
2. Certificate
ii
3. List of Abbreviations
iv
4. List of Figures and Tables
v
5. Acknowledgment.
vii
6. Chapter 1: Introduction
1
7. Chapter 2: Review of Literature
6
8. Chapter 3: Objectives and Methodology
12
9. Chapter 4: Results and Discussion - Socio-Economic Status
18
10. Chapter 5: Results and Discussion - Health Status and Health Seeking Behaviours
.27
11. Chapter 6: Results and Discussion - Occupational Health and Safety Measures
.38
12. Chapter 7: Conclusions
.49
13. References
52
14. Annexure 1: Questionnaire.
57
15. Annexure 2: Interview Guide
.66
iv
LIST OFABBREVIATIONS
BBMP - Bruhat Bengaluru Mahanagara Pal ike
BWSSB - Bangalore Water Supply and Sewerage Board
ESI - Employee State Insurance
IT - Information Technology
NMR - Nominal Muster Roll
NFHS - National Family Health Survey
PHC - Primary Health Center
PF - Provident Fund
SAGE - Study on Global Ageing and Adult Health
V
LIST OF FIGURES
Fig. No
Title
Page
Fig 5.1
Type of Major Surgeries
37
Fig 5.2
Type of Health Facilities visited in the past month
40
Fig 5.3
Preferred Health Facility for treatment
42
Fig 5.4
Substance Use
42
Fig 5.5
Type of Tobacco Used
43
LIST OF TABLES
Table No.
Title
Page
Table 4.1
Socio-demographic characteristics of respondents
25
Table 4.2
Migration
26
Table 4.3
Members of the household
27
Table 4.4
Family members in the pourakarmika occupation
27
Table 4.5
Spouse and children’s occupation
28
Table 4.6
Education of children
29
Table 4.7
Physical characteristics of houses
30
Table 4.8
Basic amenities in the houses
31
Table 4.9
Pourakarmika occupation
32
Table 5.1
Self-reported health status
34
Table 5.2
Cumulative score of self-reported health status
35
Table 5.3
Vision status
35
Table 5.4
Pattern of consumption
36
Table 5.5
Types of foods consumed
36
Table 5.6
Type of chronic ailments
38
vi
Table 5.7
Type of recurrent diseases
39
Table No.
Title
Page
Table 5.8
Symptoms experienced in the last month
40
Table 5.9
Number of sick day leaves in the last month
41
Table 6.1
Employment details of pourakarmikas
45
Table 6.2
Problems with existing personal protective equipment
46
Table 6.3
Type of work injuries
47
Table 6.4
Barriers to utilisation of ESI or Healthcard
49
Table 6.5
Perceived Impact on Health
51
Table 6.6
Additional benefits needed to improve working conditions 52
vii
ACKNOWLEDGMENT
I would like to first thank the participants for welcoming me into their lives and sharing their stories
with me. This study would not have been possible without the cooperation of the participants and the
BBMP officials and junior health inspectors. The pourakarmikas and the junior health inspectors
graciously spent time with me and provided space in their ward office to conduct the interviews.
I would like to specially thank the public health research group, Society for Community Health
Awareness, Research and Action (SOCHARA) who provided me with technical support. I would like
to extend my deep gratitude to Dr. Thelma Narayan for her constant support and guidance. A special
thanks to Mr. Prahlad IM and Mr. Alfred Raju from SOCHARA who introduced me to the field area
and helped establish a rapport with the participants.
I would like to extend my heartfelt gratitude to my guide. Dr. Harshad Thakur, for his guidance and
feedback. He gave me immense autonomy in choosing my topic of interest and was always available
to answer my questions, clarify my doubts, provide feedback and steer me in the right direction.
This study would not have been possible without the support of my friends at college who were with
me throughout the ups and downs of the college journey - Saurabh, Rachana, Debrishi and Sowmya.
I dedicate this thesis to my parents and husband, who are my pillars of strength. Their constant
encouragement, motivation and guidance are the reasons for my ability to persevere through difficult
times and fulfil our dreams.
1
CHAPTER 1
INTRODUCTION
This chapter introduces the concept of urbanisation, migration and describes the situation of the urban
poor in Bengaluru. The problem of solid waste management as a consequence of rising population in
the city is brought to notice and the role of solid waste management workers, also known as
pourakarmikas,
is introduced.
A brief description about their historical background and
socioeconomic status is presented and the chapter concludes with the rationale for the research study.
1.1 The Phenomenon of Urbanisation
India, like most emerging economies, is facing a phenomenon of rapid urbanization. The process of
urbanisation is one in which an increasing number of people leave behind villages and rural areas to
live in cities. India is urbanising at a rapid pace with a quarter of the urban population living in slum
areas.
Around one-third of Indians live in urban areas, which translates to 377.1 million of the 1.2 billion
Indians living in 7935 towns (Census 2011). Urban India contributes to 60% of the national income.
However, 26.4% of urban population is poor and 102.5 million urban people live below urban poverty
line (Times of India 2014).
1.2 Migration
A large number of rural Indians migrate to urban areas in search of better job opportunities because of
low income from agriculture and lack of other livelihood options in villages. When increasing
numbers of migrants enter cities that are already over populated, they do not find proper housing.
Therefore, 26.31% of urban population lives in slums (Government of India, Ministiy of Housing and
Urban Poverty Alleviation, National Buildings Organization 2011). Further, without formal education
or formal training, most of the urban poor work in the informal and unorganized work sector as
labourers, domestic helpers, rickshaw pullers, construction workers, small service providers, drivers,
beggars and other such temporary occupations. Many do not have any identity cards like ration cards
or voter IDs since they live in unregistered slums, pavements and squatter settlements. Without proper
identity, they are largely excluded from getting government benefits and are unaccounted in the
census (SOCHARA 2007).
2
1.3 Urban Poor in Bengaluru
Bengaluru is one of the biggest metropolitan cities in the country with 8.52 million people and is the
home for approximately 1.4 million people who live in 1,500 slums (notified and non-notified) (DNA
India 2015). According to Census 2011, “The population density in Bangalore has risen 47% in the
past decade as job opportunities and economic growth have lured people from across the nation to
India’s Silicon Valley. The number of people living per square kilometer in the city has increased to
4,378 in 2011 from 2,985 in 2001.” Like the rest of India, however, the situation of the urban poor in
Bengaluru is a major concern and the municipal corporation of Bengaluru, Bruhat Bengaluru
Mahanagara Palike (BBMP) and other non-governmental organizations are working towards the
betterment of the urban poor.
1.4 The Mounting Problem of Waste Accumulation in Bengaluru
Rising population, economic growth and increasing consumption has resulted in accelerating waste
generation. On an average, Bangalore generates 3000- 4000 tonnes of municipal solid waste per day
as per the latest estimates (Chandran et al. 2013) and the numbers are rising. Solid wastes are
classified as domestic waste, litter (organic and inorganic wastes), chemical waste and market waste.
Human and animal excreta are also mixed up with solid waste (Nagaraj et al. 2004). As per the study
by Chandran et al. (2011), Bangalore’s waste production is divided as follows - 60% of organic
waste, 30% of inorganic waste and 10% of inert waste.
The management of solid waste in Bangalore has the following four methods (Beukering et al. 1996
and Nagaraj et al. 2004):
1. Formal collection for disposal by the municipality — organised group of pourakarmikas
under the BBMP
2. Private Contractors — who have auto tippers and other waste collection vehicles as well as
their own labour force
3. Unorganised group of rag pickers for recovery and recycling
4. Waste that remains uncollected
BBMP has a centralized approach of collection and transportation of the waste to the landfills. Solid
waste management is handled by three departments in the BBMP - Health Department (waste
collection and transportation), Engineering Department (silt collection from drains) and Sanitary
Engineering Department (waste disposal) (Parameshwara 2016).
3
In Karnataka, people employed in any form of waste collection, cleaning sewage pits and drains,
sweeping roads and collecting and disposing human and animal excreta and animal corpses are called
as pourakarmikas. All municipal conservancy workers came to be referred as pourakarmikas through
a Government order in 1972 (Rangamani, Obalesha and Gaitonde 2013).
However, according to the BBMP only street sweepers, waste collectors and those who load the
lorries from the street collection points are the only ones referred to as pourakarmikas. There are
approximately 17,500 pourakarmikas in solid waste management (Economic Times 2018). The
drivers of auto tippers and helpers who collect solid waste from households are not called
pourakarmikas and all their jobs are contracted out. Those who clean sewage pits, drains and other
sewage-related components are also not called as pourakarmikas. They are employed by a different
wing of the government called Bangalore Water Supply and Sewerage Board (BWSSB). The
participants of this study are 17,500 solid waste management workers under the Health Department
whom the BBMP refers to as pourakarmikas.
1.5 Historical Background of Pourakarmikas (municipal solid waste management
workers)
Cultural values have been attached to waste for a long time now (Blincow 1986) and waste collection
in India dates back to 17th century: bones, rags and paper were the first commodities that were
collected. Historically, any occupation related to waste, garbage, handling of carcasses and human
excreta has been traditionally bound to the lowest caste (Chandran et al. 2013). In the hierarchical
structure of the caste system in India, scheduled caste is at the bottom most rung of the ladder
(Darokar 2010). Occupations assigned to scheduled castes like sweeping streets, removing garbage,
removal of dead animals, leather work, funeral work and manual scavenging are considered to be
polluting occupations and the communities engaged in it are considered as ‘untouchables’ or
‘asprushas’ in the Indian society (Beck and Darokar 2005). Therefore, members of this occupation
face discrimination, stigma, social exclusion and isolation due to the concepts of purity and pollution
(Sicular 1992).
The castes involved in waste collection in Karnataka are: Adi Andhra, Adi Dravidas (Holeyas), Adi
Karnataka (Madigas) and Bovis (Oddas) (Karanth 1995). A 2010 study on informal waste pickers by
Mythri Sarva Seva Samithi (MSSS) concluded that scheduled caste (SC), other backward caste
category (OBC) and Scheduled Tribes (ST) including nomadic tribes, sheik, kounder, Hakki Pikki
Tribes are also involved in waste-picking (as stated in Chandran et al. 2013). The survey conducted
by the Committee on Improvement of Living and Working Conditions of Sweepers and Scavengers
headed by I.P.D Salappa (1976) showed that Scheduled Castes, Scheduled Tribes, Muslims,
4
Christians and non-Scheduled Castes like Lingayats, Kurubas and Mudaliars are engaged in wasterelated occupations. Chandran et al. 2013 states that people from non-scheduled castes and religions
join the vocation due to economic pressures.
1.6 Socioeconomic Status of Pourakarmikas (municipal solid waste management
workers)
Caste based social exclusion and discrimination in the pourakarmika community is common. Social
exclusion is defined as the “limited capability of an individual to participate in the society” (Darokar
2010). Due to social exclusion that is either subtle or evident, members of the social group are
prevented from enjoying full participation in the larger society in terms of economic resources,
educational opportunities, political participation or participation in other organisations (Kadam 2017).
A study conducted on the sanitation workers in the Municipal Corporation of Ahmedabad found that
most of the sanitation workers belonged to the Valmiki community (Mishra, Dodiya and Mathur
2012). Houses of members of this community were built with mud, bamboo, plastic sheets. Many of
them did not have toilets at home. Children had high dropout rates and those who dropped out had to
take up traditional caste based occupations. Widows of workers who did their husbands’ duties
received half the wages or lesser. Many workers did not receive provident fund, medical insurance or
other benefits (Mishra, Dodiya and Mathur 2012). Such discriminations and neglect are evidence of
how the interlinking of occupation and caste affects their lives.
Similarly, a study in Gulbarga district, Karnataka, by Bhimasha and Sedamkar (2015) described how
sanitation workers experienced a low socio-economic status due to the nature of their work. Society’s
attitude along with low salary and limited job opportunities further isolated them.
The health status of pourakarmikas is also dismal, considering their role as the backbone of the waste
management system in the city. Their absence for a day will bring the city to a standstill. Despite their
crucial role in the smooth functioning of the city, pourakarmikas are largely neglected both by the
government and the society. With majority employed under contracts which have only been recently
converted to direct payment under the BBMP, pourakarmikas have low job security and inadequate
employment benefits, especially with respect to healthcare and occupational safety. Faced with the
harsh elements of nature, they are left to fend for themselves with little assistance from the state or
their employers.
5
1.7 Health Risks of Pourakarmikas
A study in Lobatse, Botswana, showed that lack of protective equipment and clothing results in
respiratory illnesses and other health issues among landfill employees and scavengers (Gwisai, Areola
and Segosebe 2014). Similarly, there are studies in the Indian context that point towards a higher
morbidity rate among sanitation workers when compared to the general population. The job of
pourakarmikas involves collecting waste — organic and inorganic, collecting recyclable material and
transporting it to the waste pick-up lorries. There is an inherent occupational risk since the wastes
that they handle can be hazardous since most of the solid waste in developing countries like India is
not segregated at the household. Therefore, the waste maybe mixed with infectious medical waste,
toxic waste materials and sharp objects to name a few. Pourakarmikas have higher exposures to
injuries and health hazards and consequently suffer from a variety of illnesses and injuries
(Jayakrishnan, Jeeja and Bhaskar 2013).
1.8 Rationale for the Study
There are studies that look into the health problems of sanitation workers across India but most of
these studies come from metropolitan cities like Mumbai. The only systematic study on the health
status of pourakarmikas in the municipal corporation of Bengaluru was conducted back in 2004 by
Nagaraj et al. The situation in Bangalore has drastically changed over the past decade with the advent
of the Information Technology (IT) Sector. Bangalore is the fastest growing city in India with an
exponential population growth and a mounting waste management problem. The number of
pourakarmikas and the scenario of solid waste management have changed since 2004 and hence, there
is a need for a study that is more relevant to the current scenario.
Majority of the waste management in the city falls under the purview of pourakarmikas and hence,
studying their health status becomes paramount from the perspective of urban development and
planning. From the rights perspective, pourakarmikas are the most marginalized section of society
with both caste, class and gender discrimination. Civil society organizations like Environment
Support Group and Alternative Law Forum are working with labour unions like BBMP Guttige
Pourakarmika Sangha to implement the law that has been passed to regularize contractual work and
remove the nexus between the government and the contractors (The Hindu 2017). Therefore, a
systematic study on the health status of pourakarmikas will be beneficial to all the stakeholders
involved, including the government, civil society organizations and the pourakarmikas, themselves.
6
CHAPTER 2
REVIEW OF LITERATURE
This chapter details the existing literature on the various health risks associated with solid waste
management, occupational injuries, use of personal protective equipment and safety measures. The
chapter then gives insights into available literature on alcohol and smoking habits of solid waste
management workers. Finally, the chapter lists literature on the various health ailments (divided by
organ systems) experienced by workers who work with waste in the developing countries, specifically
India.
2.1 Health Risks of Solid Waste Management
Solid waste management involves risks to not only those involved in the occupation but also the
residents living near the landfills, dumping grounds or waste collection points. A country’s waste
composition depends on many factors — income level, industrialisation and cultural norms (Cointreau
2006). Sanitation workers in poor and developing countries have higher exposure to risks because of
the lack of proper and safe equipment, improper waste segregation, open dumping grounds and more
labour intensive work (Cointreau 2006). Developed countries manage their waste much better than
developing nations due to their strong regulatory and enforcement frameworks. Such regulatory
bodies are either weak or absent in developing nations.
Risks are associated along all points of the solid waste management chain - collection of waste,
transportation of waste and disposal of waste. According to the study by Cointreau, 2006, “risks to
health of workers can be caused due to many factors including: composition of the waste itself that
can be toxic, allergic or infectious; decomposition of waste materials may lead to toxic gases, dust,
particulates; handling of waste in accidents; working in unsafe and traffic conditions; processing of
waste that may result in explosions, fire, odours, air and water emissions.”
2.2 Types of Occupational Injuries
In developing countries, waste management is labour intensive and waste is collected directly by
hand. This increases direct exposure to all types of waste as well as all other pests like rats and
rodents that feed on the waste. Occupational accidents and injuries are higher among sanitation
workers than the general population (Kadam 2017). A study by Mishra, Dodiya and Mathur (2012)
reported many cases of blindness among sanitation workers while they were on duty. Another study
7
by Jayakrishnan, Jeeja and Bhaskar (2013) found incidents of animal bites and rat bites to be higher in
sanitation workers. A study on Mumbai sewage workers found 26% experienced occupational injuries
due to work (Giri, Kasbe and Aras 2010). Needle pricks and injuries by sharp objects are more
common among workers in municipal teaching hospitals of Mumbai (Palve et al. 2014). A study in
Egypt found that sweepers have more occupational accidents and are constantly in contact with blood,
sharp metallic objects, needles, faeces, mice, rats, dead animals, mosquitoes (Ewis et al. 2013).
A study by Gizaw, Gebrehiwot, Teka and Molla (2014) conducted in Ethiopia showed that 64% of
work related injuries occurred annually among municipal solid waste management workers. The study
reported that the factors causing such a high rate of injuries were: inadequate quantity and quality of
protective equipment; and workers who were not properly trained to use the equipment. Workers were
mainly injured on the hands, legs, neck and back. Injuries were caused due to sharp objects, heavy
waste containers, dust, falling objects and strained body postures. There was also a seasonal pattern in
the number of accidents - more accidents occurred during summers perhaps due to more waste
collection in summer and improper clothing. The same study also reported a direct relationship
between age and number of accidents. It reported an inverse relationship between education level and
number of work related accidents. Increasing levels of education was found to be associated with
decreased incidence of work related injuries. Alcoholism was positively associated with work related
injuries. Workers without health and safety training were more likely to be injured and those with
personal protective equipment were less likely to be injured. (Gizaw et al. 2014).
2.3 Use of Personal Protective Equipment and Safety Measures
It is quite evident that lack of personal protective equipment and occupational safety measures can
lead to increased health risks resulting from contact with solid waste. Despite this knowledge, there is
abundant literature from the Indian context that illustrates the dismal condition working conditions of
sanitation workers.
In Ahmadabad Municipal Corporation, 90% of the sanitation workers (including workers handling
human excreta) reported not receiving any safety equipment from the corporation (Mishra, Dodiya
and Mathur 2012). Similarly, in Kozhikode Corporation, Kerala, 78% of women workers reported
handling waste with bare hands and only wearing sandals to step on waste (Jayakrishnan, Jeeja and
Bhaskar 2013). Even in Nagpur, none of the sweepers used protective equipment because they were
not provided with the safety gears regularly and no training was given (Sabde and Zodpey 2008).
Among sewage workers in Mumbai, awareness regarding the importance of protective equipment like
goggles, mask and gumboots was very low (Giri, Kasbe and Aras 2010). Although around 85% of
sweepers working in Mumbai Municipal Teaching Hospital reported using personal protective
equipment, close to half did not use it on a regular basis (Palve et al. 2014).
8
2.4 Smoking and Alcohol Consumption
A study of Mumbai sewage workers showed all the respondents were involved in smoking, tobacco
and alcohol consumption (Giri, Kasbe and Aras 2010). Smoking tobacco was seen in 26.2% of the
employees and smokeless tobacco addiction was seen in 32.2% of the sweepers employed in a
municipal teaching hospital in Mumbai (Palve et al. 2014). Percentage of sweepers who consumed
alcohol in the same study was 33.3% and 24.7% reported addiction to alcohol. On the contrary, a
study conducted among women solid waste management workers in Kozhikode Corporation area in
Kerala showed that they neither had the habit of tobacco consumption nor any other addictions
(Jayakrishnan, Jeeja and Bhaskar 2013).
2.5 Health Ailments
The different health ailments that sanitation workers experience will be classified based on organ
systems as follows:
2.5.1 Respiratory Ailments
Sanitation workers in Ahmadabad Municipal Corporation spent around 25% of their income on
medical expenditure and respiratory problems such as tuberculosis, respiratory infections were high
among the workers (Mishra, Dodiya and Mathur 2012). In the Kozhikode Municipal Corporation
study, it was seen that exposure to organic dust containing high concentrations of bacteria, fungi,
toxic gases and other gases increased the chances of respiratory illness (Jayakrishnan, Jeeja and
Bhaskar 2013). Among sweepers in a Mumbai teaching hospital, 7.9% have respiratory problems due
to high exposure to dust, aerosols and volatile organic matters (Palve et al. 2014).
Chronic bronchitis due to occupational exposure and smoking habits was seen in street sweepers of
Nagpur (Sabde and Zodpey, 2008). However, when controlled for the effect of smoking, a significant
relationship was seen between street sweeping and respiratory issues in a study conducted in Egypt
(Ewis, Rahma, Mohamed, Hifnawy, and Arafa, 2013).
Waste collection is done in high-traffic density areas in developing countries where the vehicular
pollution is not controlled and the job of solid waste management is so physically challenging that it
requires high pulmonary ventilation and breathing through the mouth rather than the nose (Cointreau-
Levine 1998). Consequently oxygen consumption is much higher in waste collectors than the
recommended limits (Cimino 1975). A study in Lobatse, Botswana in 2014 by Gwisai, Areola and
Segosebe showed high prevalence of respiratory illnesses due to lack of protective clothing and safety
9
equipment, atmospheric dust, offensive odours and absence of soil cover materials in landfill
employees and scavengers.
2.5.2 Musculoskeletal Disorders
Musculoskeletal problems are the most commonly reported ailment among sanitation workers. Waste
collection and sweeping puts undue stress on the major joints and there is high risk for low back pain,
disorders of the neck, shoulders and arms (Cointreau2006). In Mumbai, 68% of sewage workers
reported musculoskeletal problems like backache and weakness (Giri, Kasbe and Aras 2010).
Musculo-skeletal problems had the highest morbidity affecting 20.6% of sweepers working in the
municipal teaching hospital in Mumbai being affected by them (Palve et al. 2014). Even in Bangalore
sweepers, 29.9% of the participants reported musculoskeletal problems (Nagaraj et al. 2004). Among
women solid waste management workers in Calicut Corporation area, 56.5% had musculoskeletal
problems and the joints affected in the order of most commonly reported pain were knee, back,
shoulder, elbow, ankle and neck (Jayakrishnan, Jeeja and Bhaskar 2013). It is seen from global
literature that lower back disorders are strongly associated with occupations which involve work-
related lifting and forceful movements (Jayakrishnan, Jeeja and Bhaskar 2013). Therefore, sanitation
workers in India who work under difficult circumstances with improper equipment and safety
measures have high musculoskeletal problems.
2.5.3 Gastrointestinal Ailments
When protective equipment is not provided to sweepers, there is more risk of infectious diseases,
particularly gastrointestinal diseases. More than half of the sanitation workers in Mumbai city had
diarrhoea, flatulence and worm infestations (Giri, Kasbe and Aras 2010) and 9.7% of sweepers in the
Mumbai teaching hospital reported gastrointestinal problems (Palve et al. 2014).
In Kozhikode
Municipal Corporation, there was a significant statistical association between not bathing after work
and skin diseases (p = 0.041), jaundice (p = 0.043) and diarrhea (p = 0.001) (Jayakrishnan, Jeeja and
Bhaskar 2013). Unlike other studies, only 2% of the women workers reported diarrheal diseases in the
last year perhaps due to good awareness, good food hygiene and toilet practices (Jayakrishnan, Jeeja
and Bhaskar 2013).
In a study conducted in Egypt on street sweepers and waste collectors, Hepatitis C Virus seropositive
cases were found (Ewis et al. 2013). Sweepers were also infested with parasites like Entameba
histolytica, Giardia and H. Nana. When compared to university employees, sweepers had much higher
prevalence of gastrointestinal diseases. This is again explained by the level of socio-economic status,
10
working conditions, hygiene practices and awareness about the importance of hygiene and health
(Ewis et al. 2013).
2.5.4 Urinary and Reproductive Tract Infections
Urinary tract infections were reported in 2.2% of the sweepers in a Mumbai teaching hospital (Palve
et al. 2014) while 2.8% of pourakarmikas in Bangalore reported genitourinary infections (Nagaraj
et.al 2004). Around one third of women workers in Kozhikode Corporation reported urinary and
reproductive tract infections (Jayakrishnan, Jeeja and Bhaskar 2013). There are no toilets and drinking
water facilities at work and hence, this results in decreased water intake and delayed emptying of
bladder leading to urinary tract and reproductive tract infections. Interestingly, there was no difference
in the results between married or unmarried women highlighting the fact that occupation is more
important than marital status in this context.
2.5.5 Vector Borne Infections
Waste collection sites can be breeding sites for insects, rodents and other pests. Bites and direct
contact with rodents increases the risk of leptospirosis. Aedes aegypti mosquito the dengue vector
breeds in small, clean, water pools and since there are many coconut shells in solid waste
management sites which could be mosquito breeding areas (Jayakrishnan, Jeeja and Bhaskar 2013).
Dengue and malaria were also reported in women workers in Kozhikode Municipal Corporation
(Jayakrishnan, Jeeja and Bhaskar 2013) and 12.73% of the sanitation workers in Mumbai teaching
hospital reported malaria (Palve et al. 2014).
2.5.6 Ophthalmic Ailments
The highest morbidity among sewage workers in Mumbai City was due to eye problems which were
reported by 70.7% workers (Giri, Kasbe and Aras 2010). Eye redness, burning sensation, irritation
and watering of the eye were the common complaints. Palve et al. (2014) also found ophthalmic
conditions in 8.6% of sweepers in Municipal Teaching Hospital of Mumbai. 2.5% sweepers in
Bangalore reported problems of the eye according to the 2004 study by Nagaraj et al. Around one
third of women working in solid waste management in Kozhikode Corporation, reported eye ailments
(Jayakrishnan, Jeeja and Bhaskar 2013).
11
2.5.7 Cardiovascular and Endocrinological Ailments
Among Mumbai sewage workers, it was reported that 12% had hypertension, 6.7% had ischemic heart
disease and 3.3% had diabetes mellitus (Giri, Kasbe and Aras 2010). Sanitation workers in a Mumbai
teaching hospital also reported 17.2% hypertension, 6.7% diabetes mellitus and 1.9% cardiovascular
system diseases (Palve et al. 2014). Similarly, the 2004 study on sweepers in Bangalore Municipal
Corporation showed 18.9% had hypertension (Nagaraj et al. 2004).
2.5.8 Nutritional Deficiencies
In the health survey conducted by Bombay Municipal Corporation in 1994, 1.2% was found to have
anemia (Giri, Kasbe and Aras 2010). Close to 100% of male sweepers and 72.4% of female sweepers
were found to have mild to moderate anemia in 2004 (Nagaraj et al. 2004). 14.4% of women workers
in Kozhikode Corporation area in Kerala were found to be malnourished with a BMI of less than 18.5
(Jayakrishnan, Jeeja and Bhaskar 2013). In Egypt, a study comparing street workers with clerical
workers showed that lack of proper diet and under-nutrition caused more anaemia in street workers
(Ewis et al. 2013).
2.5.9 Skin Ailments
Skin infections and skin related issues are extremely prevalent in sanitation workers. 3.11% of street
sweepers in Bangalore reported skin ailments, which was the third most common ailment reported
(Nagaraj et al. 2004). Skin ailments were seen in 52% of sewage workers in Mumbai city (Giri, Kasbe
and Aras 2010). Among women solid waste management workers in Calicut Corporation, 37 %
reported skin lesions due to dermatitis, eczema, bacterial or fungal infections (Jayakrishnan, Jeeja and
Bhaskar 2013). The same study reported nail infections due to frequent contact of the workers with
fungi and bacteria in dirt and water. Additionally, personal hygiene practices like not bathing after the
job was associated with skin diseases. A comparative study between street sweepers and university
workers in Egypt showed huge differences in complaints of skin irritations with street sweepers
reporting higher incidences of skin complaints due to direct contact with waste and dust (Ewis et al.
2013).
12
CHAPTER 3
OBJECTIVES AND METHODOLOGY
This chapter describes the broad objectives, specific objectives, research questions and methodology
of the study. It includes details about the sampling strategy, research design and data collection
method. Finally, the chapter concludes with the data analysis plan and challenges faced on the field.
3.1 Broad Aim
The study aims to understand the health status and occupational safety of solid waste management
workers called pourakarmikas of Bruhat Bengaluru Mahanagara Palike (BBMP).
3.2 Specific Objectives
1. To understand the socio-cultural and economic context of the municipal pourakarmikas
2. To describe the health status of the municipal pourakarmikas
3. To identify their healthcare seeking behaviour
4. To identify occupational safety measures and healthcare entitlements provided by the government
5. To understand barriers of utilization of the above entitlements from the perspective of the
pourakarmikas
3.3 Research Questions
1. What is the social, economic and cultural background of pourakarmikas?
2. What are their working conditions and safety measures?
3. Are there any occupational safety measures implemented?
4. What are the common health problems faced by them?
5. What are the health treatment facilities from where they seek treatment?
6. What other means do they resort to take care of their health?
7. What are the government entitlements provided to safeguard their health?
8. Are the pourakarmikas aware of their entitlements?
9. What are the difficulties faced by them in utilizing these governmental entitlements?
13
3.4 Research Design
The aim of the study is to understand the health status of municipal sanitation workers. Considering
the time and logistical constraints, a cross-sectional and descriptive study was conducted.
In order to meet the study objectives a mixed method approach was adopted. The quantitative study
captured information from the pourakarmikas and the qualitative study included insights from
officials.
3.5 Operational Definitions
Pourakarmikas: Solid waste management workers i.e. street sweepers and waste collectors in the
municipal corporation of Bengaluru City
Health Status: Measurements of health included self-reported ratings on 7 domains of health mobility, pain and discomfort, cognition, sleep and energy, affect, interpersonal activities and vision.
Working Conditions: Availability of proper clothes and tools for work; basic amenities like drinking
water, restrooms, changing rooms, place to rest and eat; provision of breaks during work hours and
paid leaves
Occupational Safety Measures: Safety measures in the workplace like masks, boots, gloves,
availability of first aid and other measures that have a strong focus on primary prevention of hazards
Healthcare Seeking Behaviour: Sequence of remedial actions that individuals undertake to rectify
perceived ill-health by visiting formal or informal healthcare facilities including home remedies
Healthcare Entitlements: Entitlements to access healthcare facilities like Employee State Insurance
(ESI) Scheme or other health insurance coverage.
Migrants: All residents who are not born in Bengaluru City
Chronic Ailment: An ailment that is life-long and continues to persist although the intensity may
differ at different points in time for example diabetes, hypertension, arthritis
Recurrent Ailment: An ailment that occurs repeatedly with periods of complete remission for
example headaches, back pain or redness of the eye
3.6 Study Area
The study was conducted in Bengaluru District
14
3.7 Study Period
The data was collected between May 2018 and June 2018
3.8 Demographics of Study Area
Bangalore is the capital city of the South Indian state of Karnataka and has an estimated population of
10 million. It is the third most populous city in the country and is well known as the “Silicon Valley
of India’ because of its role as the major hub of Information Technology companies in the country.
Table 3.1
Demographics of Bengaluru
Description
Census 2011
Population
96.22 lakhs
Population Growth
47.18%
Area Sq. Km
2,196
Density/km2
4,381
Proportion to Karnataka’s Population
15.75%
Table 3.2
Socio-Demographics of Urban-Rural Bengaluru
Description
Rural
Urban
Population (%)
9.06%
90.94%
Total Population
871,607
8,749,944
Male Population (%)
53.26%
52.1%
Female Population (%)
46.74%
47.9%
Sex Ratio
877
920
Child Sex Ratio
953
943
Average Literacy
78.21%
88.61%
Male Literacy
84.54%
91.66%
Female Literacy
70.92%
85.27%
15
3.9 Ward Map of Bengaluru
■............. ■
159
Bangalore City has 10 municipal zones and 198
administrative
wards.
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.
Figure 3.1: Ward Map of Bengaluru (Source: www.mapsofindia.com)
BANGALOftfe
N
LEGEHC"
Ward
Ward Map
A
P.
2I 1 i
3 L<‘
5
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25- 26:\
Map not to Swfe
Copyright C 2015 www.m4ptofindU.cofT
3.10 Sampling Universe
All the municipal solid waste management sanitation workers in Bengaluru City: 17,500
3.11 Characteristics of Participants
Inclusion criteria:
•
Should be employed under the job title “Pourakarmika” in the BBMP
•
Willing to participate
Exclusion criteria:
•
Not willing to participate
•
Not an official employee
•
Employed in the Solid Waste Management department but under a different designation like
auto driver or lorry driver
3.12 Sampling Strategy
Quantitative Study: The sampling technique followed was purposive sampling.
16
Bengaluru city has 10 municipal zones and 198 wards. Out of the 198 wards, 2 wards were
purposively selected for the study based on inputs from resource personnel working on the issue of
pourakarmikas. From each ward, all the pourakannikas were selected. This resulted in 61 samples
from one ward and 39 samples from the other ward.
Qualitative Study: Purposive Sampling technique was followed.
Five key informants were purposively selected based on consultations with resource personnel in
BBMP. Key informants were identified based on their involvement with solid waste management in
the city and the corresponding wards. Once they key informants were identified, those willing to
participate were included in the study.
3.13 Data Collection Instrument Preparation
Quantitative: The questionnaire was designed by using National Family Health Survey and WHO’s
Study on Global Ageing and Adult Health questionnaires are references. Modifications were done
considerably to suit the present context and new appropriate questions were added.
The questionnaire consists of self-reported questions on socio-economic status, dietary pattern, health
habits, health-seeking behaviour and occupational and safety measures. There were mostly closed
questions with a few open-ended questions. The questionnaire was tested before implementing on the
field.
Qualitative: Interview guides were prepared for the key informant interviews.
3.14 Data Collection Procedure
Quantitative: After the two wards were identified purposively, the junior health inspectors of each
ward were contacted to request a convenient time to conduct the interview with the pourakarmikas.
Based on the availability of the pourakarmikas and their health inspectors, the interviews were
scheduled. All the interviews were conducted in the respective BBMP Ward Office. Each of the
respondents was allowed to take a break from their regular work schedule and attend the interview.
The interviews were conducted in as confidential a manner as possible and the researcher ensured that
the supervisors were not present so that the participants could answer in a comfortable manner.
However, some interviews were conducted in the presence of other participants as long as all the
participants were comfortable in each other’s’ presence.
The interview was conducted by the researcher in the local language of Kannada and all the answers
were recorded in real-time on the interview schedule in English.
17
Qualitative: The first key informant was identified based on their position in the BBMP solid waste
management department. With their recommendation, the other four key informants who were also
BBMP employees (contractual and permanent) were identified. The responses to the interview
questions were written down in a notebook in real time.
3.15 Ethical Considerations
All respondents were explained the details of the study including the reasons for why the study was
being conducted. It was clearly mentioned that no monetary benefits would be obtained by
participating in the study. Additionally, participants were given the opportunity to withdraw from the
study at any point in time and no reasons would be asked. After the respondents fully understood the
details and consent was obtained from them, the interviews began. No personal identifiers were used
during the interview process and all information was only used for the purpose of research.
3.16 Field Experiences
The main challenges faced were contacting the BBMP officials since Karnataka had parliamentary
assembly elections at the time of the data collection in May 2018. This delayed the interviews
considerably and the interviews had to be conducted towards the end of the scheduled period.
Once the elections ended and the BBMP official in-charge of solid waste management was available
for an interview with the researcher, the official cooperated in identifying the wards and the
corresponding key informants. Rapport was established with the mid-level supervisory staff in the
wards selected for the study. Continuous engagement with the officials and the pourakarmikas
enabled for basic rapport to be established. The data collection process then proceeded smoothly and
all the interviews were conducted in the ward offices with the cooperation of all the respondents.
3.17 Data Analysis
Responses to the questionnaires were analysed using SPSS software and then presented in Excel
tables. The transcripts from the key informant interviews were thematically analyzed. Manual coding
of the transcripts were done and the codes were organized and arranged to generate themes.
18
CHAPTER 4
SOCIOECONOMIC STATUS OF POURAKARMIKAS
This chapter describes the socio-demographic profile of pourakarmikas. It also provides information
about the migration status, language fluency, characteristics of the household and physical features of
their housing. Finally, the chapter touches upon the reasons for joining the pourakarmika occupation
and other household members who are involved in the same occupation.
4.1 Socio-Demographic Profile
Table 4.1 describes the socio-demographic characteristics of the pourakarmikas (N= 100). Majority of
the participants were women (81%) between the age group 30-50 years. Since the sampling was done
exhaustively in both the wards, we can assume within reason that the number of women in the
pourakarmika occupation is higher than men. This is perhaps due to the nature of work, which mainly
involves sweeping the streets and picking up waste. Men employed as pourakarmikas were involved
in loading lorries with garbage from street comers and from waste pick-up points. The sweeping was
primarily done by women. Additionally, with the introduction of auto tippers for door-to-door
collection of waste in many neighbourhoods, most pourakarmikas were not involved in direct
collection of waste from households. Only in a few localities, they collected wastes from households,
stored them in the pushcarts and dumped them in the waste collection centres.
The mean age of the respondents was 40.7 years with standard deviation 9.24 years and the median
age was 40 years. Hindus comprised of 73% of the pourakarmika population with Christian and
Muslim were 23% and 4% respectively. The most commonly reported caste was Scheduled Caste
(79%). Five percent of the respondents identified with no particular caste. When it came to presence
of BPL card, 79% reported having a BPL card while 21% said that they did not have a BPL card or
they had to apply for it. Sixty percent of the respondents were illiterate and among those who were
literate, 75% had some form of primary schooling. Formal education and schooling saw an
improvement in the next generation (Table 4.6) i.e. 92% of the children of pourakarmikas attended
schools. Pourakarmikas who were married comprised of 68% of the population and 24% had spouses
who had passed on. Languages spoken included Telugu (66%), Kannada (19%) and Tamil (15%).
19
Table 4.1
Socio-demographic characteristics of respondents
TOTAL
%
TOTAL
%
Education Status
Gender
Male
19
Illiterate
60
Female
81
Literate but no formal schooling
1
Primary School
30
9
Age
21-30
15
High School
31 -40
39
BPL Card
41-50
30
Yes
79
51-60
16
No
21
Marital Status
Religion
Hindu
73
Single
3
Christian
23
Married
68
Muslim
4
Separated
5
Widow/Widower
24
Caste
General Caste
4
Language Spoken
Scheduled Caste
79
Telugu
66
Scheduled Tribe
1
Kannada
19
No Caste
5
Tamil
15
Did not answer
11
Number of Migrants
63
4.2 Migration
Sixty three out of the 100 respondents were migrants in the study. The reasons for migration reported
in order of frequency were marriage (58.3%), livelihood (33.33%) and family (7.9%). Majority of the
women respondents stated that they moved to Bangalore from their hometown after their wedding.
Respondents of both sexes stated that they moved to Bangalore in search of better job opportunities
either before marriage or after marriage. Around 8% of the respondents said that they moved to
Bengaluru in childhood with their parents.
While 37% pourakarmikas interviewed are native Bangaloreans, 34% of the pourakarmikas have
migrated from Andhra Pradesh alone. Even among those who are bom and raised in Bangalore,
majority are Telugu speaking. This is consistent with other studies that report most of the
pourakarmikas in Karnataka are migrants or descendants of migrants from neighbouring Andhra
20
Pradesh since the locals did not want to involve themselves in the occupation (Parameshwara 2016).
The remaining 20% of the pourakarmikas reported that they have migrated from other parts of
Karnataka, especially North Karnataka which is also similar to what was reported by Parameshwara
2016 and only 4% are from Tamil Nadu.
Among those who migrated, mean years spent in Bengaluru was 24.5 years with standard deviation
9.87 years and median of 25.0 years. Only six respondents migrated to Bangalore less than 10 years
ago and 79% were fluent in a language additional to their mother tongue. All these are indicators of
strong cultural assimilation and enable pourakarmikas to assimilate into the community despite being
migrants.
Table 4.2
Migration
Reasons for Migration
%
Livelihood_______________
Family__________________
Marriage_________________
21
5
37
Place from which migrated
Andhra Pradesh
34
Other parts of Karnataka
20
Tamil Nadu
4
Number of Years Spent in Bengaluru
Up to 10 years
6
11 to 20 years
20
21 to 30 years
24
31 to 40 years
11
41 to 50 years
2
Born and Raised in Bengaluru
37
4.4 Household Composition
Average number of members in the household is 4.74 and standard deviation is 1.66. The median
number of members in the household is 5. In terms of other socio-economic characteristics, 44% lived
in joint families while 50% lived in nuclear families. This dwindling number ofjoint families could be
a by-product of urbanisation that is seen even in the pourakarmika community. Since 63% of the
21
pourakarmikas are migrants, this perhaps explains the rising number of nuclear families because those
who migrate from villages cannot afford to bring their extended families to the cities.
As seen in Table 4.4, 57% of the pourakarmikas had relatives (excluding parents and spouse) who are
pourakarmikas. 14% and 11% of the pourakarmikas interviewed had mothers and fathers respectively
who were also involved in the pourakarmika occupation. Among those who are married, 34% stated
that their spouses were in the same occupation. On the contrary, only 3% of the children of
pourakarmikas are employed in the same profession.
Interestingly, however, it is important to note that although no explicit mention of a family tradition or
family history of working in this occupation was mentioned. This could be perhaps due to internalised
stigma about the occupation but the study could not explore this aspect further due to time constraints.
Table 4.3
Members of the Household
Number of Members in Household
%
UPTO 3 members
14
4-7 members
70
9 to 12 members
4
Did not answer
12
Type of Family
Alone
2
Joint Family Same Kitchen
42
Joint Family Separate Kitchen
2
Nuclear Family
50
Did not answer
4
Table 4.4
Family Members in the Pourakarmika Occupation
Family Members
(%)
Relatives who are pourakarmikas
57
Mother is/was a pourakarmika
14
Father is/was a pourakarmika
11
Spouse is/was a pourakarmika
33
Children are pourakarmikas
3
22
4.3 Familial Characteristics
Spouse’s occupation was reported as pourakarmika by 33% of the respondents and 29% reported that
their spouse’s occupation as daily wage worker. 8% reported that their spouse is unemployed and 5%
reported that their spouse is retired. The remaining reported miscellaneous jobs including carpentry,
painting etc.
49% of the respondents have spouses who are illiterate and 4% have spouses that are literate without
any formal schooling. Among those who have some schooling, 25% have attended primary school,
15% have attended high school and 2% have done diploma courses.
Table 4.5
Spouse and Children’s Occupation
Spouse’s Occupation
%
Pourakarmika
28
Posthumous PK
5
Daily Wage (Construction Worker etc)
29
Unemployed
8
Retired
5
Others
2
Spouse’s Education
Illiterate
49
Literate (no formal schooling)
4
Primary School
25
High School
15
IT Diploma/Office Secretary
2
Ninety five respondents reported that they have children and among them 91.6% attended school.
71.3% went to government school and 18.4% went to private school. This is a sharp increase in
school attendance among children when compared to their parents. This is a positive trend that shows
that literacy has been increasing in their familial context. Seven respondents stated that they sent their
girl children to government school and boy children to private school. This is an example of gender
discrimination although there was no scope to explore this further.
23
Table 4.6
Education of Children
N = 95
%
Children attending school
87
91.6
Type of School Attended
N = 87
Government School
62
71.3
Private School
16
18.4
Daughter in Government School and Son in Private School
7
8.04
Did not answer
2
2.3
4.5 Physical Characteristics of the Houses
Pucca and semi-pucca houses are the most common type of houses reported with only 3% respondents
reporting living in kuccha houses. 61% of the respondents live in rented houses, 37% own their own
houses and 1% live in leased houses.
The average number of rooms per house reported is 2.76 (SD 1.11) and median is 3. The average
number of windows per house is 1.97 (SD 1.3) and median is 2.
Seven percent of the pourakarmikas in the study reported living in houses with no windows. This
could potentially have an impact on their health.
Only 37% owned the houses in which they lived while the rest (62%) lived in semi-pucca or pucca
rented accommodation. This is a consequence of migration as well as economic status. The
respondents lived in relatively large houses with a median of 5 family members and 3 rooms.
Unfortunately, 3% respondents stated that they lived in kuccha houses while 7% lived in houses with
no windows. These could have potentially harmful effects on their health due to indoor air pollution,
poor ventilation and exposure to smoke from cooking (only 17% have a separate kitchen). Among
those who responded, no one had a problem with access to drinking water and several participants had
multiple sources for drinking water.
24
Table 4.7: Physical Characteristics of houses
(%)
(%)
Type of House
Rooms in house
Kuccha
3
1 to 2
43
Semi-Pucca
40
3 to 4
50
Pucca
56
5 to 6
5
Did not answer
1
Did not answer
2
Number of
House-Ownership
Windows
Rented
61
No windows
7
Own
37
1 to 2
59
Lease
1
3 to 4
25
Did not answer
1
5 to 6
4
Did not answer
3
Majority of the pourakarmikas have a separate toilet at home or a common toilet for the building
(86%). Eleven percentage use the public Pay and Use toilets and 1% resort to open defecation.
Only 17% have a separate kitchen at home while the rest use the living room or any other room in the
house as a kitchen. LPG/Natural Gas is the most common type of cooking fuel used (83%) and wood
is used by 10% of the interviewees. The remaining 5% of the respondents use wood, kerosene or
biogas.
Majority of the neighbourhoods in which the pourakarmikas live have municipality waste collection
services (87%). 4% reported disposing their own household waste in street corner, 4% reported
disposing in street dustbin and 4% use their own dustbins at home.
In terms of drinking water source, all the respondents have sufficient drinking water supply (N=98; 2
did not respond). Majority have Cauvery water supply which is a piped drinking water supplied from
the government (54%). 18% have both Cauvery and borewell water supply; 15% have only borewell
water supply and 6% use mineral water supply - either solely or in combination with other water
supplies. The use of mineral water is questionable and the data needs to be validated again. Only 2%
get water supplied by water tanker.
25
Table 4.8: Basic Amenities in the houses
%
Garbage Disposal
%
building
13
Municipality Waste Collection
87
Separate Toilet at Home
73
Street Corner
4
Pay and Use
11
Street Dustbin
4
Open Defecation
1
Dustbin at home
4
Did not answer
2
Did not answer
1
Type of Toilet
Common Toilet for the
Drinking Water Source
Separate Kitchen
Yes
17
Piped drinking water only
54
No
81
Piped drinking water and borewell
18
Don't Know
2
Borewell only
15
Tanker water
2
Cooking Fuel
Piped drinking water and mineral
LPG/Natural Gas
83
water
3
Kerosene
2
Corporation water
3
Wood
10
Mineral water
1
kerosene or LPG
3
Borewell and mineral Water
2
Biogas
1
No answer
2
Did not answer
1
Wood in combination with
4.6 The Pourakarmika Occupation
This study delved into the reasons why people chose the pourakarmika occupation and interestingly,
the reasons emerged were contrary to the popular notion that it was a hereditary occupation mandated
by their caste. Most respondents (57%) reported that the main reason for joining the pourakarmika
occupation is that they consider the job to be better than their previous occupations - domestic work,
construction work, agriculture and plumbing. Many women reported that domestic work was
unfavourable for them since they had to spend many hours working in the water, which affected their
health. Moreover, the timings were too long and the salary was insufficient. The respondents felt that
their previous jobs that were in the unorganized work force gave them little benefits, irregular wages
and the availability of work year-long was questionable. They were involved in hard physical labour
and had to work under the harsh sun for many hours in a day. Especially for mothers with school
going children, the timings of pourakarmika occupation of working between 6:30 am to 2:30 pm were
26
convenient. Additionally, the work was less dangerous or strenuous like construction work and the
quantity of work was lesser than in domestic work. Women reported that it was difficult to take care
of their children when they were involved in construction work or domestic work.
Twenty two percentage of the respondents reported that they considered the pourakarmika occupation
as a good livelihood option - most of them were not involved in other jobs prior to this and even if
they were, they did not mention it during the interview. They said they preferred this job due to the
timings and stable salary.
Eleven percentage reported that they joined this occupation because they knew other family members
in the same occupation. Although none of the respondents explicitly mentioned that this was their
family tradition, most of them reported that this was a common occupation in their family and hence,
they decided to continue in the same line of work.
The remaining respondents quoted financial hardship (1%) or inability to find jobs elsewhere (9%) as
reasons for joining the occupation.
Table 4.9
The Pourakarmika Occupation
Reasons for joining the occupation
%
Better than domestic work
27
Consider this as a good livelihood option
22
Better than construction work
18
Better than other types of work - agriculture, plumbing, vegetable/fruit selling
12
Family tradition/other family members introduced to occupation
11
Unable to find jobs elsewhere
9
Financial Hardship
1
T1
CHAPTER 5
HEALTH STATUS OF POURAKARMIKAS
This chapter explains the different aspects of the health of pourakarmikas including a self-scoring on
different domains of health (adapted from WHO’s Study of Global Ageing and Adult Health). The
chapter also delves into the dietary habits of the pourakarmikas (adapted from NFHS). The chapter
discusses major surgeries, chronic diseases, recurrent diseases and symptoms experienced in the last
month. The health-seeking behaviour of the pourakarmikas in terms of their preferred health facilities
and health facility that they visited in the past month is reported. Finally, the chapter touches upon
alcohol use, tobacco use and knowledge about substance abuse in the community.
5.1 Health Status
Interviewees were asked to score themselves on the following seven aspects of their own health —
mobility, pain/discomfort, cognition, sleep and energy, affect, interpersonal activities and vision.
Mobility: 67% reported of the respondents reported that they never or rarely had any difficulty with
household activities. 28% reported that they had difficulties sometimes, most of the times or always
with household activities. 5% did not respond.
On the contrary only 16% of the respondents stated that they have problems with moving around but
30% reported that they have problems with vigorous physical activity.
Pain and discomfort: 52% of the respondents have body aches sometimes, most of the times or
always. This is an important finding since majority report the problem. 37% state that they fall ill with
fever, cough and cold sometimes while 45% state that they never fall ill or 14% rarely fall ill.
Cognition: Overall self-reported cognition is good. 84% state that they have no difficulty
concentrating or remembering things. 10% state they sometimes have problems with memory and 1%
has problems most of the times and 1% has this problem all the time.
Sleep and energy: Difficulty waking up or sleeping was seen sometimes, most of the times and
always in 9%, 5% and 3% of the respondents respectively. 76% reported that they had no difficulties
in sleeping and 78% said that they felt well-rested/refreshed during the day.
Affect: 81% said that they never feel sad or depressed and 72% reported that they never feel anxious
or worried. 13% and 20% reported sadness/depression and anxiety/worry respectively sometimes,
28
most of the times or always. Those who experienced these symptoms were either single mothers, lost
their spouses or were experiencing family problems.
Interpersonal Activities: 91% of the pourakarmikas had never or rarely experienced any difficulties in
interpersonal interactions or participation in the community. 85% had no problems dealing with
conflicts or tensions.
Table 5.1: Self-Reported Health Status
Most of the
Description
Never
Rarely
Sometimes
Times
Always
Difficulty in Household Activities
59
8
16
7
5
Difficulty moving around?
73
11
8
4
4
Difficulty in vigorous physical activity
61
9
14
5
11
37
11
32
7
13
45
14
37
1
3
84
4
10
1
1
76
7
9
5
3
78
8
8
3
3
Feeling sad, low or depressed
81
6
7
4
2
Feeling worried or anxious
72
8
15
3
2
95
2
3
0
0
82
3
13
2
0
Mobility
Pain and Discomfort
Body aches
Physical illness like fever, cough, cold,
headache
Cognition
Difficulty concentrating or remembering
things
Sleep and Energy
Difficulty in waking up, sleeping
Not feeling well-rested/refreshed during
the day
Affect
Interpersonal Activities
Difficulty with personal relationships or
participation in the community
Dealing with conflicts and tensions with
others
29
Cumulative Health Status:
The self-reported health score of each individual was added for each of the 12 questions by assigning
the following values: never = 0, rarely = 1, sometimes =2, most of the times = 3, always = 4. The
scores for individuals ranged from 0 to 48. Categories were made further as follows - 0-16 as good,
17 - 32 as average and 33 - 48 as poor. As seen in Table 5.2, 90% of the individuals rated their health
as “good” while 8% rated their health as “average” and finally, 2% belonged to the “poor” category.
Table 5.2: Cumulative Score of Self-Reported Health Status
Cumulative Score
Good (0-16)
Average (17-32)
Poor (33 - 48)
%
90
8
2
Health status of the pourakarmikas was overall good with very small percentage of the study
respondents complaining of any difficulties in the domains of physical, mental, emotional and social
health. There could be a tendency of the respondents to not reveal the true nature of their problems
due to a variety of reasons, including fear of losing their job if they complained. This bias could have
been overcome had the researcher approached the respondents through a community based
organisation or after continued engagement with the respondents. Due to time constraints, although
the rapport established was cordial and healthy it might not be sufficient to ensure the respondents
reveal all their issues. Secondly, since the SAGE scale is subjective and it is difficult to interpret and
generalise the findings to other contexts. However, the strength of the scale is that it provides an
overview of the various aspects of functional health.
Vision Status
Nineteen percentage of those interviewed reported wearing contact lenses or spectacles while 23%
said that they experienced blurred vision or problems with seeing. Among the 23 who reported
blurred vision, only 9 wear glasses or contact lens. The remaining fourteen have not sought medical
help to improve their vision.
Table 5.3: Vision Status
Vision
Yes
No
1
Used contact lens or glasses
19
81
2
Experienced blurred vision
23
77
30
5.2 Dietary Habits
30% of the respondents have home-cooked meal all three times of the day. These respondents
are usually older and live close to their work. Hence, they can go back home during their break
at 10:30 am to have a meal. 60% respondents reported that they eat home-cooked meals twice a
day. Minority of them eat only twice a day while most of them report that their breakfast is
eaten in a hotel since they do not have time to cook early in the morning before coming to work
at 6:30 am. The breakfast eaten is usually idly, upma, poori or chapatti. A small fraction (6%)
state that they eat home-cooked meal only once a day and 4% do not eat at home even once.
Table 5.4: Pattern of Consumption
Number of times
home cooked meal is
eaten
%
None________ ______ 4______
Once________ ______ 6______
Twice
60_____
| 30_____
All three times
The diet comprises of milk/curd on a daily or weekly basis for 87% of the respondents.
Pulses/beans (76%), dark green leafy vegetables (74%), eggs (57%), chicken/mutton (66%) are
consumed weekly by majority of the respondents. Fruits are consumed occasionally (55%) or
weekly (29%) by most of the respondents. Fast foods saw a split between 41% who state that
they eat outside the house daily and 41% who state they never eat fast food. Fried foods is
consumed by most either occasionally (45%) or never (30%). 72% said that they never have
cold drinks while only 18% report drinking cold drinks occasionally.
Table 5.5: Type of Foods Consumed
Daily
Weekly
Occasionally
Milk/Curd
74
13
ll
0
Pulses/Beans
15
76
6
3
Dark Green Leafy Vegetables
15
74
10
1
Fruits
10
29
55
6
Eggs
9
57
26
8
Fish
4
22
36
36
Chicken/Mutton
26
66
“7
"T
Fried Foods
5
19
45
30
Fast Foods
41
4
12
41
Cold Drinks
3
7
18
72
Never
31
5.3 Major Surgeries
A total of 74 respondents (both men and women) reported major surgeries. 87 surgeries were reported
in total with few individuals reporting multiple surgeries. Tubectomy was the most commonly
reported surgery (71%) followed by C-section (13%). Hand/leg surgeries were undergone by 3
individuals - 2 men and one woman. Among the men, only 32% stated that they had surgeries
including limb surgeries and throat surgery. On the contrary only 85% of the women interviewed had
undergone a major surgery (either tubectomy or C-section or both). Although the majority of the
surgeries reported by women are obstetric surgeries, further research is needed to understand if there
is a higher prevalence of surgeries in women pourakarmikas when compared to men.
Figure 5.1: Type of Major Surgeries
Hand + Leg
Operations
3%
Appendectomy
Other
4%
'Wl 7% '
Tubectomy
71%
5.4 Chronic Diseases
Chronic diseases were reported in 46% of the individuals. Cardiovascular diseases were seen in 17
individuals followed by musculoskeletal issues in 9 individuals. Diabetes and thyroid issues were seen
in 4 and 5 individuals respectively. Respiratory ailments were seen in 8 individuals and ophthalmic
ailments in 6 individuals. Auditory problems and anemia was seen in only one individual each.
Gastrointestinal problems were seen in 4 individuals and skin allergies in 3 individuals. Two women
reported dysmenorrhea and two men reported alcoholism when asked about chronic diseases.
Chronic diseases reported were hypertension, musculoskeletal problems (chest pain, back pain, knee
pain, body aches), respiratory ailments (breathing difficulties, asthma, cough), diabetes, skin-related
KOra^an<3a',a4
e-no
^^0
?
32
conditions (itching, redness, infections), ophthalmic conditions (irritation, watering, itching, redness)
and gastrointestinal problems (stomach pain, diarrhoea). These findings are similar to other studies
conducted in Mumbai (Palve et al. 2014), Bangalore (Nagaraj et al. 2004) and Calicut (Jayakrishnan,
Jeeja and Bhaskar 2013).
A unique finding from this study is that women reported gynaecological health problems like
dysmenorrhea which has not been explored in the previous studies. Dysmenorrhea was reported under
three different instances - chronic diseases, recurrent diseases as well as symptoms experienced in the
last month. Only two studies - Palve et al (2014) on sweepers in a municipal teaching hospital and
Jayakrishnan, Jeeja and Bhaskar (2013) touched upon the higher prevalence of genitourinary
infections among women sanitation workers when compared to other employees in Calicut Municipal
Corporation. This throws light on the fact that most of the studies conducted on health status of
sanitation workers focus on general health problems and often miss the gender related health
problems. Therefore, it is important to incorporate the gender lens and consider occupational health in
the context of biological as well as societal gender roles.
Table 5.6: Types of Chronic Ailments
Types of Chronic
Ailments
%
Hypertension
15
Hypotension
2
Body aches
6
Hip/Knee Pain
2
Arthritis
1
Vision Problems
6
Asthma
1
Difficulty
Breath ing/Allergy
3
Thyroid Disease
5
Diabetes
4
Stomach related problems
4
Skin allergies
3
Dysmenorrhea
2
Alcoholism
2
Anemia
1
Hearing Problems
1
33
5.5 Recurrent Health Problems
Majority
(88%)
of the
interviewed
pourakarmikas
recurrent
reported
health
problems.
Musculoskeletal problems (42%) topped the list followed by headache (39%); cough/cold/fever (36%)
and body aches (26%). Eye irritation/redness was seen in 15% of the individuals followed by
difficulty breathing (8%) and stomach related illnesses (7%).
Only 3 individuals reported skin
allergies and 1 reported dysmenorrhea and 1 reported frequent urination.
Table 5.7: Types of Recurrent Diseases
Types of recurrent health
problems
%
Musculoskeletal Problems:
back pain, hip pain, chest pain
42
Headache
39
Cold/Cough/Congestion/Fever
36
Tiredness/Body aches
26
Eye Irritation/eye redness
15
Difficulty Breathing
8
Stomach related
7
Skin itching/allergies
3
Dysmenorrhea
1
Frequent Urination
1
5.6 Symptoms Experienced in the Last Month
When asked about the symptoms they experienced in the last month, 62 respondents said they in fact
did experience symptoms.
The most commonly reported symptoms were cold/cough/congestion/fever (25%) and bodyaches
(9%). Headaches (8%) and musculoskeletal problems (6%) like hip pain/back pain were the next most
frequently reported problems. Dysmenorrhea was seen in women (4), stomach related ailments, skin
itching, typhoid, boils on leg and other miscellaneous were also reported.
34
Table 5.8: Symptoms experienced in the last month
Description of Symptoms_____
Cold/cough/congestion/feve r
Bodyaches with fever/cold/cough
Headache
Musculoskeletal Problems
Dysmenorrhea
Stomach related ailments
Skin itching
%
25
9
8
6
4
3
1
Miscellaneous = typhoid, boils on leg, follow-up of DM
6
5.7 Health-seeking Behaviour of Pourakarmikas
5.7.1 Health Facility visited in the Last Month
When asked if they sought any treatment in the last month, out of the 62 who said that they had some
symptoms only 55 said that they availed a remedy. 54.5% said that they went to a private healthcare
facility and 36.4% said that they went to a pharmacy. Only 9.1% said that they went to a government
healthcare facility.
This is consistent with what was reported earlier about the preference for
government facilities being low.
Figure 5.3 Type of Health Facility visited in the last month
Ha
Pharmacy
,
• X'
36%
Private
55%
35
Another interesting finding was that among 62 respondents who reported that they experienced
symptoms/illness of any kind in the last month, majority of them (71%) did not do anything about it
and instead continued working. 17.7 % took up to 2 days of leave. Most of the pourakarmikas said
that they could not afford to miss a day’s work since their salaries would be deducted and hence,
decided to take care of their illness after their work hours.
Table 5.9: Number of sick day leaves in the last month
Number of sick days at work
Resumed work immediately
Half a day_________________
1 to 2 days_________________
3 to 5 days_________________
1 week____________________
%
44
2
9
2
22 to 30 days
2
5.7.2 Preferred Health Facilities
Only 22% of the pourakarmikas said that they prefer a government healthcare facility when they are
ill. Majority of them preferred going to a private health facility (62%) or pharmacy (4%).
12
respondents did not answer the question or said that they did not have the need to go to a healthcare
facility thus far.
As with the general population, pourakarmikas also prefer private health facilities (62%) over public
health facilities (22%). When asked about the health facility that they visited in the past month, only
9% of the respondents who visited a health facility actually went to a public health facility (Figure
5.3). This discrepancy in their reported preference and actual utilisation is not uncommon. This
indicates that pourakarmikas, even those who report preference for public health facilities, actually
visit private health facilities for various reasons including convenience of timings, distance as well as
more trust in private health practitioners.
36
Figure 5.2 Preferred Health Facility for Treatment
Did not
answer/Did not
have the need
12%
A
Public
22%
Pharmacy/SelfMedication
4%
5.8 Substance Use
Tobacco use was seen in 48 respondents while 11 respondents reported alcohol use. No alcohol
consumption was reported among women. When asked about substance use, only one respondent said
that they knew of ganja use in their community..
Figure 5.4: Substance Use
33
Tobacco Use
Alcohol Use
Smokeless tobacco consumption (70.6%) far exceeded the smoking tobacco consumption (29.4%).
Pan with tobacco was the most common form of tobacco consumed followed by bidi, guthka and
cigarettes. 15 women reported consuming pan without tobacco. Women consumed smokeless tobacco
mixed with paan while men consumed tobacco in all forms — bidi, cigarette, pan and guthka. Many of
37
the respondents confined their tobacco use only during work hours. ‘7/ masks the smell of garbage, ”
said many respondents and some even reported that they started chewing tobacco after joining the
occupation so that they do not have to experience the stench. Few women attributed their habit to the
company of coworkers, tlWe all chew paan and spend time together during our breaks. ”
When it came to alcohol use, eleven out of the nineteen men said they drink alcohol on a regular
basis. All the men pourakannikas work with large piles of garbage that has to be loaded on to the
lorry. Most of them have to walk through heaps of garbage inside the lorry as well as the street
corners from which they pick it up. The men, therefore, revealed that without having a drink of
alcohol in the morning, they will be unable to work in such filthy and physically strenuous conditions.
The alcohol gives them “energy” and allows them to work faster while handling the garbage. Similar
findings of higher prevalence of alcohol and tobacco use among sanitation workers are seen in other
studies (Palve et al. 2014 and Giri, Kasbe and Aras 2010).
Figure 5.5: Type of Tobacco Used
r- 4.ki n Cigarettes, 1
Guthka, 2
Pan with
tobacco, 22
38
CHAPTER 6
OCCUPATIONAL HEALTH AND SAFETY
This chapter describes the working conditions of the pourakarmikas in terms of safety measures and
work related injuries. Healthcare benefits provided to them by the BBMP and the pourakarmikas’
perspectives on barriers faced in terms of availing these entitlements are also documented. The latter
part of the chapter describes the perception of pourakarmikas in terms of how the occupation has
impacted their health and the benefits they would like to receive to improve their working conditions.
Finally, the chapter concludes with salient themes that arose from the interviews with key informants
regarding the provisions given to the pourakarmikas from the government, the difficulties the
pourakarmikas face and the challenges the government experienced by officials in terms of
implementation and management.
6.1 Details of Employment
Among the pourakarmikas interviewed seventy five were contractual employees (not permanent
employees). From January 2018, they were promised a direct contract with the government and hence,
their salary and benefits like ESI and PF would be handled by the BBMP. Before January 2018, the
contractual pourakarmikas were working for a contractor who had in turn been selected by the
government through a tendering process. At the time of interview in May 2018, although the BBMP
had promised to do away with the middle-men contractors, their presence was still strong. The
pourakarmikas were still managed by them in one of the wards where the research was conducted.
The remaining 25 pourakarmikas were permanent employees under the BBMP. They were employed
by the BBMP decades ago and are said to be on the Nominated Muster Roll (NMR). They receive a
higher salary than the contractual workers and also have a health card that promises them free
treatment in all empanelled hospitals. However, apart from two supervisors in the study, others did
not have any pension benefits.
The job roles were of 4 main categories - sweeping, loading lorries, loading autos, and supervision.
Each ward had one pourakarmika supervisor and hence, the study which was conducted in two wards
had 2 supervisors in the sample. 83% of those interviewed were street sweepers. 10% were involved
in loading lorries i.e. they collect the waste from street comers, street dustbins and load the municipal
lorries. All the participants involved in loading lorries were men. Only 3% were loading autos i.e.
they assist the auto tippers that go door to door for waste collection.
In general, those involved in load autos were not called pourakarmikas, and were primarily employed
by the contractors. In our study, there were only 3 who did the job of loading autos though their
39
designation was a pourakarmika. The remaining 2 participants did multiple jobs - sweeping, loading
lorries, helping the supervisors, gardening and other odd jobs.
The average year of employment was 13.62 years (S.D 9.7 years) and median was 7 years. The range
was from 2 years to 40 years.
Table 6.1: Employment Details of Pourakarmikas
Terms of Employment
%
Permanent
25
Contract
75
Job Role
Sweeper
83
Auto Loader/Driver
3
Lorry Loader
10
Multiple Jobs
2
PK Supervisor
2
Work Experience (in years)
2 to 10
57
11 to 20
11
21 to 30
29
31 to 40
3
6.2 Occupational Safety Measures Provided
The BBMP is mandated to provide personal protective equipment (PPE) to all the pourakarmikas.
This includes uniforms, gloves, masks, chappals for sweepers and gum boots for lorry loaders. In
addition to the PPE, government medical officers from Urban Primary Health Centres (U-PHCs) are
required to visit the pourakarmikas of their respective wards and conduct health check-ups once in 2-3
months. These well thought out and thorough guidelines to improve the living and working conditions
of pourakarmikas exist since the time of I.P.D Salappa report of 1976.
However, the ground realities are very different from the policy documents. Around one third of the
pourakarmikas do not use PPE and among the two thirds who do use, many do not use it on a regular
basis. Majority (78%) of the pourakarmikas had problems using the PPE. The most common
complaint was regarding the mask (33%). Respondents complained that the masks were ill fitting,
became very hot and caused problems with breathing. Therefore, most of them tie a piece of cloth
40
over their noses as well as another piece of cloth to cover their heads. Standing in the sun for long
periods of time causes headaches and it is the second most common health problem reported by the
pourakarmikas (Table 5.7). There was no provision of caps or sunglasses to protect them from the
harsh sun or dust.
The second most common complaint was related to gloves (29%). Gloves tore easily and workers
could not grip the broom or pick up waste properly with gloves since they tend to slip. Some even
complained that the smell of the gloves was hard to tolerate after handling garbage and they needed to
wash the gloves every day to use, which becomes a cumbersome process. If the gloves tears or wears
out, they do not get replacement gloves on time. These are some of the deterrents from using gloves.
Instead, they use plastic bags to cover their hands when touching the waste and dispose these bags
every day.
Among those who load lorries, the common complaint was the footwear (9%). Gum boots are worn
which are too loose and all the waste leaks into the boots when they are sorting through heaps of
garbage. Sometimes, the replacement boots take a long time to arrive and many have experienced foot
injuries even while wearing boots. The women pourakarmikas also have problems with the chappals
that are given since they are not replaced if worn out.
Five percent complained that they lost the PPE that was given to them or they were not given PPE at
all. Finally, a small proportion (2%) of the workers reported they feel comfortable working without
PPE and viewed PPE as an impediment to their work.
Table 6.2: Problems with existing Personal Protective Equipment
Reports of problems with PPE
%
Gloves
29
Footwear
9
Mask
33
PPE not given/lost
5
Can work without it
2
Only 13 pourakarmikas, all belonging to the same ward reported that there are additional safety
measures excluding PPE. 64.3% reported among them reported that there was a first aid box in the
office for any small injuries or cuts experienced on the job and the remaining 35.7% considered the
weekly exercises under the supervision of the health inspector was a safety measure that benefited
them.
41
6.2 Work Injuries and Healthcare Entitlements
6.2.1 Types of Work Injuries
Around one third experienced injuries while working. Cuts on hands or fingers were the most
common types of injury with 16 respondents stating that they have been cut by a sharp object like a
glass piece at least once and more commonly multiple times while handling the waste.
Cuts on both hand and feet were reported by 8 individuals and 3 individuals reported getting cuts only
on their feet. All these three individuals involved in loading lorries cut their feet when glass pieces
pierced through their gum boots. Needle pricks was seen in 3 individuals - they were usually syringes
in the waste that injured them. Dog bites was also experienced by 3 individuals and finally, 2
individuals reported that they injured themselves by tripping and falling down while at work.
Table 6.3: Type of Work Injuries
Work Injuries
%
Experience of work injuries
32
Cuts on hands/finger only
16
Cuts on foot/leg only
3
Cuts on hand and feet
8
Dog bites
3
Needle pricks
3
Fell down and injured
2
More men experienced work injuries as compared to women and what was more unique was the way
in which they tended to their wounds - rarely did they go to any professional healthcare provider.
They used the grease oil from the lorries to apply on their injuries, tied a piece of cloth around them
and continued working. Even for needle pricks, glass cuts, cuts by other sharp objects, the most
common method of treatment was self-care - home remedies like turmeric was used in some cases but
mostly, the workers covered their wounds with a piece of cloth and continued working. Only in cases
of deep cuts or dog bites, did the workers go to a health professional. Most reported that they had to
pay out of their own pockets for the treatment while few reported that the government paid for their
treatment.
42
This sheds light on the dismal situation of how workplace injuries are handled. Due to the fear of loss
of pay, most workers do not take a break to seek medical help even when they are injured or
experience any form of illnesses.
In one of the wards in the study, with new health inspector introduced measures like a sanitary pad
dispenser, first aid box and exercises twice a week. The pourakarmikas of this ward, primarily the
women, appreciated these unique interventions by the health inspector and reported that they have
experienced many benefits as a result of them.
6.2.2 Employee Benefits and Healthcare Entitlements
Majority (72%) of the employees reported that they received an appointment letter or ID card from
the employer. However, 28% had no proof of employment. 70 pourakarmikas reported that they were
aware of the benefits that they receive as being part of this occupation and 30% said they do not know
much about what the benefits are. When these 70 were probed further about their benefits, only 37
mentioned ESI, PF or healthcard as benefits. The remaining reported salary, uniform and PPE as
benefits and the others said that although they knew there are benefits they were not sure what exactly
the benefits entailed. However, on the contrary, when asked directly about ESI and healthcard, 84%
said that they had heard about the two terms and knew that they are eligible for it. 16% on the other
hand, said that they had not even heard about ESI or health card. Although majority of the workers
mentioned that they were aware about ESI or health card, only 9 had actually utilised these services.
6.2.3 Barriers to ESI or Health Card Utilisation
When asked about the barriers to utilisation, 47 individuals out of the 100 individuals in total reported
that they have never gone to the facilities. No further explanation was provided. Thirteen individuals
said that they had not been provided any ESI card and hence, they did not utilise the services and 13
other individuals mentioned that they do not know the procedures on how to use the ESI.
Eleven employees mentioned that the ESI hospital was too far away and one person mentioned that
they had to miss a whole day of work to go to the ESI hospital. Five respondents felt that the process
of getting prior authorisation to use the ESI card from the head contractor and other formalities
involved in seeking care from the ESI hospital was very cumbersome. Seven individuals who have
the BBMP health card which only the permanent employees are eligible for mentioned that they can
use the health card only for in-patient procedures and hence, for minor out-patient procedures they
seek care from private facilities. Among the remaining employees, 2 stated that they need more
information like location and one respondent felt that they do not treat patients properly in the ESI
hospital. 3 respondents preferred other facilities like private hospital or charitable hospital over ESI or
other government hospitals and hence, they do not seek services from the ESI hospital.
43
Table 6.4: Barriers to Utilisation of ESI or Health Card
Barriers to Utilisation
%
Have never gone
47
No card is given
13
Too far away
11
Lose whole day of work
1
Too many formalities
5
Need more details like
location
2
Don't know the procedures
13
Used the card (mainly IPD)
procedures
7
Don't treat the patients well
1
Prefer other facilities
(charitable, government,
private)
3
Awareness about entitlements associated with their occupation among the workers with 70%
reporting that they know they are eligible for certain benefits. However, when these 70 were probed
further about the types of benefits for which they are eligible, only 52% mentioned about Employee
State Insurance (ESI) and Provident Fund (PF) benefits. The remaining 48% said that they did not
know the exact nature of their benefits and some mentioned salaries and PPEs as benefits.
On the contrary, the permanent NMR pourakarmikas were well aware of their benefits which included
a BBMP health card that they could utilise for hospitalisations as well as out-patient visits. The
contractual pourakarmikas, who were at the time of the interview, still for all practical purposes under
the middle-men contractors, had little or no idea about how to use their ESI card or what their PF
benefits meant.
Key informant interviews with mid-level supervisory BBMP officials gave further insight into this
issue. The contractors withheld the ESI cards of the workers because many of the workers on the
payroll submitted to the BBMP were actually non-existent. The inflated numbers of workers projected
by the contractors was to exploit the contract system by employing only half the workforce as
promised and thereby, profit illegally. In some situations, the key informants reported to the
researcher that the contractors had made no contribution to the ESI or PF accounts of pourakarmikas
44
who had been working for more than 5 years. ESI and PF account numbers were also falsified and in
reality, these accounts did not exist.
On a positive note, from the time when data was collected for the purposes of this study in May 2018,
the situation for pourakarmikas has improved. From July 2018, all the pourakarmikas received
salaries directly into their bank account from the government. Their ESI numbers had been handed
over to them and they also have access to their PF accounts. Without the middle-men between the
workers and the government, the situation in terms of accessibility to health care services at the ESI
hospitals and other government healthcare facilities is projected to improve.
However, just ensuring that pourakarmikas are aware about their right to free healthcare treatment is
not sufficient. In the study, it was seen that although all the 25 permanent pourakarmikas had
awareness about the benefits of the BBMP health card, only 9 utilised them. Some of the barriers cited
by both contractual as well as permanent pourakarmikas are the bureaucratic procedures to obtain
permission to utilise the healthcard or ESI card is very cumbersome. Therefore, they avail these
services only for in patient procedures. Private facilities are more convenient because their timings do
not conflict with the pourakarmika work timings. Additionally, they are closer to their houses and
hence, one does not have to take leave from work or spend on transportation. Few reported that they
have a good rapport with their local doctors and trust them more. Therefore, they would rather spend
money out of pocket to see a doctor whom they trust than seeing a doctor in a government health care
unit who is not very familiar with them and who sometimes does not treat them well.
Therefore, it is important to explore further the reasons that prevent the pourakarmikas from using
their healthcare entitlements. Measures must also be taken to ensure that their out of pocket healthcare
expenditure is reduced.
6.3 Perceived Impact on Health and Facilities Needed
6.3.1 Perceived Impact on Health
Majority (73%) of the respondents perceived that their occupation has no impact on their health. On
the contrary, 7% of the respondents felt that their health has actually improved due to various reasons.
Some stated that they have lost weight and are healthier because of the job. Others feel that this job is
better than their previous physically strenuous job like domestic work or construction work. Majority
feel that they have made friends on this job and this has improved their overall health.
Only 17% of the total respondents perceive a negative impact on their health due to their occupation.
3% did not have any opinion. Of those who perceived a negative impact on their health, 8 reported
45
more body aches due to the occupation. 4 reported more allergies and 4 felt that their health has
declined because they are unable to eat, drink or use the bathroom regularly because of work
conditions. 2 reported that their overall health has declined.
Table 6.5: Perceived Impact on Health and Facilities Needed
Health Impact
%
No impact on health
73
More body aches and pain
8
Health has improved - lost weight, made
friends
7
More allergies and cold/cough
4
Cannot eat on time, drink water and go to
the bathroom
4
Overall health declined
2
Do not know
3
6.3.2 Facilities Needed
Only 25 out of the 100 pourakarmikas interviewed felt that all their needs were being met at work.
Among the remaining 75 who desired certain facilities that improve their working conditions, 32
reported that toilet facilities and drinking water facilities need to be arranged for them. 14 reported
lack of toilet facilities as a major hurdle and some women reported that separate toilets for women,
especially when menstruating is an absolute necessity. 13 reported that better quality personal
protective equipment as well as basic tools like brooms, shovel need to be provided to enable them to
work better. 9 respondents wanted job security by converting the position from contractual to
permanent. Salary related issues like timely payment of salaries, proper system of attendance and
increase in salary was requested by 6 interviewees. Permanent housing or any form of accommodation
was also requested by 4 respondents. Employees also requested a place to eat and a place to rest
during work. More breaks were requested and monthly leave options were also brought to notice. 4
interviewees had no opinion or did not answer when asked about additional benefits that they would
like to be provided with.
46
Table 6.6: Additional benefits needed to improve working conditions
Requirements
Toilet and drinking water facility at work
Toilet facilities
Canteen or place to eat
Place to rest
Monthly leave
Better quality PPE and better equipment to deal with the garbage
Salary-related issues
Convert to permanent job
Provide housing
No answer/Don’t know
No problems - satisfied with all the facilities available
%
32
14
5
2
2
13
6
9
4
4
25
An interesting finding from the study is that 73% of the pourakarmikas felt that their occupation had
no impact on their health. Among those who reported health problems arising the most common
problems were musculoskeletal problems like hip pain, back pain and knee pain. This can be
attributed to the poor working conditions that require the pourakarmikas to bend and lift large
amounts of garbage, bend to sweep roads and collect waste. The second most common negative health
impact reported is allergies (skin and eye) and cold/cough. If provided with better ergonomic tools
and equipment to handle the wastes and better PPE to protect from the hazards of waste collection,
these two problems could be alleviated to some extent. Not surprisingly, when asked about what they
would like to see improve in their work environment, one of the most popular answers was improved
quality of personal protective equipment and tools to well-designed tools work efficiently without
undue strain on their health.
Pourakarmikas also report that the lack of drinking water and toilet facilities has a major impact on
their health. In order to relieve themselves, some workers have to walk more than a kilometre to find a
public pay and use toilet since the households do not allow them to enter their houses due to caste and
47
occupational stigma. Similarly, drinking water is not easily available and few households and hotels
oblige to give drinking water to pourakarmikas on duty. This means that while working under the hot
sun, many pourakarmikas go long hours without drinking water or walk all the way to the ward office
to drink water. A feasible and economic solution to this problem has to be formulated.
Pourakarmikas have no resting place for them during breaks, no place to eat and women do not have
changing rooms. All these deprivation of basic necessities for a safe and healthy work environment
will have detrimental cumulative impacts on their health and well-being.
When considering other occupations that are available to the urban poor, some pourakarmikas are of
the opinion that their occupation is more desirable. The fixed salaries, timings and job security (now
that they are contracted directly by the BBMP) are the attractive aspects of their job. A small
proportion (7%) of pourakarmikas is of the opinion that their health has improved because their job is
less physically strenuous and they have a good company of colleagues to work with.
However, the overall consensus among the solid waste management workers is that basic facilities
like proper tools and
machinery to
handle garbage,
good
quality
PPE, toilet/drinking
water/eating/resting facilities, regular work breaks and monthly leaves are critical requirements for
them to perform better at work and improve their quality of life.
6.4 Perspectives of BBMP Officials
The following are the results that emerged from key information interviews with the BBMP officials.
6.4.1 Facilities Provided to Pourakarmikas by BBMP
"Uniforms are provided to all pourakarmikas, both contractual and permanent, so that there is
dignity of work, ” said one of the key informants from the BBMP. All pourakarmikas are supposed to
receive health care entitlements. Pourakarmikas receive ESI card if they are contractual and BBMP
Health Card if they are permanent. These cards ensure that all their hospitalisations in BBMP
empanelled hospitals are free of charge and out-patient visits are also covered. Additionally, BBMP
doctors are scheduled to visit the pourakarmikas once in 2-3 months and conduct regular health
checkups. "As preventive and promotive measures, personal protective equipment like masks, gloves
and chappals are provided after several consultations with the groups working with pourakarmikas
and the pourakarmikas themselves, ” said the second key informant.
Salary of permanent pourakarmikas is Rs. 18,000 and they get a BBMP health card. They do not
receive any pension or Provident Fund (PF). On the other hand, contractual pourakarmikas receive a
48
salary of Rs. 16,000 but get only Rs. 12,500 in-hand after deductions for Employee State Insurance
(ESI) and Provident Fund (PF).
Additionally, mid-day meal is supplied every day at 10:30 am to all the pourakarmikas across the city
from The Akshaya Patra Foundation (TAPF), an NGO that provides nutritious and hygienic food.
However, only 10-20 out of the 60 workers consume this mid-day meal and the others prefer to eat
outside in the hotels.
6.4.2 Challenges faced by BBMP staff
Two main challenges were iterated by all the five key informants: the problem of delayed salaries and
withholding of ESI cards by contractors.
Salaries were delayed due to various reasons — the newly installed biometric attendance system was
not conducive to many workers. They complained of faulty machines that did not register their finger
prints and hence, they felt that their salaries were unreasonably deducted even when they were present
on the job. Biometric attendance was installed to overcome the problem of “free-riders” who were
employees who existed only on paper and not in reality.
Contractors tend to inflate the numbers of employees, falsify ESI accounts and PF accounts and resort
to other illegal measures to increase their profits according to one of the key informants. ESI cards,
even if present, are withheld from the workers by the contractors. “Many workers are not even aware
of their ESI eligibility,
said one of the key informants. This has led to many workers resorting to
multiple loans and bankruptcy due to rising healthcare costs. This was a very disturbing trend that was
seen in both the wards and the mid-level BBMP officials were in a helpless situation since they could
not counter the political pressure of the contractors.
On the other hand, corruption existed even between the lower-level supervisory staff and
pourakarmikas. The pourakarmikas had to bribe their supervisors to ensure that they were not marked
absent on certain sick days as the system does not allow more than one day of leave per month.
49
CHAPTER 7
CONCLUSIONS
The role of pourakarmikas as the backbone of the city’s waste management system is indisputable.
This study was conducted with the broad aim to understand the health status of solid waste
management workers called pourakarmikas in Bengaluru city. It also intended to understand the
context in which pourakarmikas live and work. Their occupation health, healthcare entitlements and
safety measures were also explored.
7.1 Socioeconomic Status
Municipal pourakarmikas working in Bengaluru belong primarily to the scheduled caste community
and are Telugu speaking. These are families migrated to Bengaluru from North Karnataka and Andhra
Pradesh for livelihood options. Mainly women pourakarmikas migrated to Bengaluru after their
marriage. Most workers are married and live with their joint families in rented pucca/semi-pucca
houses with LPG/natural gas connection, drinking water supply and indoor bathroom facilities. Most
pourakarmikas had family members who were also involved in the pourakarmika occupation and
pourakarmikas who were previously employed considered the fixed salary and fixed timings of their
occupation as attractive options that other jobs in the unorganised work sector could not offer.
7.2 Health Status
Self-reported health status appears to be largely good among the pourakarmikas. Similarly, self
reported food consumption was fairly balanced and most pourakarmikas not consume fried foods, soft
drinks and other junk foods. Mid-day meals provided by the government were utilised only by a small
proportion and most preferred to eat in a hotel during their morning break. The disadvantage of their
occupation was the early morning timings which prevented them from consuming breakfast and other
timely meals.
Most women pourakarmikas have undergone major surgical procedures, the most common of which
was tubectomy followed by C-section. Hypertension, arthritis, asthma, diabetes and anemia are the
chronic ailments while headache, eye problems, cough/cold/fever; breathing difficulty and stomach
related ailments are the recurrent illnesses.
50
7.3 Working Conditions
Pourakarmikas are supplied with gloves, face masks, boots and chappals. However, there are many
complaints including some claiming that they were not supplied any personal protective equipment.
Other issues are poor quality and design of the PPE, and no stocks to replenish the existing PPE when
it is either lost or worn out.
Lack of sufficient bathroom facilities, place to rest and eat, drinking water facilities and changing
rooms for women also have an impact on the health and wellbeing of pourakarmikas. Delayed salaries
are another serious concern that hampers pourakarmikas from fulfilling their most basic necessities,
including health.
7.4 Healthcare Seeking Behaviour and Healthcare Entitlements
For minor illnesses, pourakarmikas use home remedies or take over the counter medication. Even for
work-related injuries, rarely do they visit any health facility. Instead, they treat their cuts/wounds with
grease oil or turmeric. If they are ill at work, pourakarmikas do not take a leave of absence for the fear
of loss of pay. Instead, they visit private health facilities that are closer to their homes after work.
Only permanent pourakarmikas visit empanelled hospitals for treatment of major ailments and for
hospitalisations as they are aware of the benefits of their health card. Most contractual workers visit
private health facilities and not the ESI hospital for which they are eligible. Lack of knowledge about
the entitlements, withholding of the ESI card by the contractors, distance and bureaucratic procedures
to navigate within the ESI hospital are the deterrents that prevent pourakarmikas from using ESI
facilities. Therefore, pourakarmikas prefer paying out of pocket in a private health facilities even if it
means that they have to take loans or go into debt.
7.5 Recommendations
7.5.1 Better occupational safety measures and working conditions
Pourakarmikas should be provided with good quality personal protective equipment that is
designed well. The masks should be well-fitted, gloves should be durable and boots should be
designed in a way that prevents leakage into the feet. Additionally, caps and goggles should
also be provided to prevent headaches from the sun and eye irritation respectively. A
continuous supply chain of these safety gears should be maintained for replacements.
51
Basic cleaning tools like brooms, shovels and equipment to pick up large amounts of waste by
the lorry loaders should be provided to reduce the undue burden. The cleaning tools should
also be well designed to reduce strain on the musculoskeletal system.
Training should be provided on how to use safety equipment as well as the work equipment.
First aid kits should be mandatory in all ward offices with health inspectors and
pourakarmikas trained in basic first aid to treat work place injuries before being referred to a
higher facility.
Finally, basic amenities like bathroom facilities, changing rooms, drinking water facilities and
a place to eat/rest during breaks must be provided to ensure better working conditions and
overall wellbeing.
7.5.2 Healthcare Entitlements
Pourakarmikas must be made aware of their healthcare entitlements and their ESI cards
should be handed to them. The procedures to avail ESI services should be simplified and
assistance should be provided to help the pourakarmikas navigate the system.
Linkages between the urban Primary Health Centres (PHC) and the solid waste management
department should be strengthened so that there is a regular health check-up by the medical
officers from the PHCs. Screening and early detection for common non-communicable
diseases should also be conducted. Awareness sessions on preventive and promotive
measures to reduce common ailments like musculoskeletal problems can also be conducted.
^tjbrary anc
'^SOPHEA-SOCH
e-no
1
52
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30
57
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JOINTLY OWNED WITH FAMILY MEMBERS
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rw
SPECIFY’
TYPE OF TCHLFT VSEO
SEPARATE TOILET AT HOME
(X>MMON TOILET TOR THE BUILDING
PLW K TOILET PAY aed USE
OPEN DEEFCATION
OTHER {SPECIFY?
i.
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SEPARATE KITCHEN
Yf&'NO
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HOW MANY DAYS OF PHYSICAL ILLNESS LIKE
FIVER, CXHGILCOLD. HEADACHE OR OTHER
PHYSICAL ILLNESS DID YOU HAVE’’
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HAVE YOU USED GUSSSLS OR C0NTM1
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62
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(SPECIFY)
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CATARACT
OTHER EYE VISITS PROBLEMS
(SPECIFY)
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HEARING PROBLEMS
(SPECIFY)
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(SPECIFY)
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(SPECIFY).,
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WHERE DO YOU GENERALLY GO FOR
TREATMENT R>R THE ABOVE CHRONIC
DISEASED?
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HMAWTIC OVARY SYNDROME
OTHER OBSTETRIC GYNECOLOGICAL DISEASES
(SPECIFY)
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USED TO SEEK BLI ORE
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(SPECIFY)
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[ 2(132
WHAT ARE "YOUR RECURRENT Hl AL TH
PROBLEMS? iCIRt11 AU THAT APPLYl
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W.
MU
liv
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XHL
XVIM
June
XX.
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XIV.
(OLD
LOUGH
FEVER
LEG PAIN
BACK PAIN
HIP PAIN
HEADACHE
(Tim PAIN
GENERAL BODY ACHES
TIREDNESS
EYE IRRITATION
SNEEZING
DHTiaiLTY BREATHING
SKIN INFI CHON
BURNS
CUTSDRUl^S
OTHER
ISPK1FY)
: 2023
IN YOUR OPINm WHAT ARE THE REASONS I OR VOI R RECURRENT HEALTH PROBLESfeS)? |t>pe of
IwrasM mhwnm, IM of piopei bealth £kiIi5*:s hck of ckw Mr*uKr’food ttcl
2024
WHAT ARE THE FACTORS THAT HAVE HELPED YOU MOST IN (WNG WITH YOUR lUNESSCESl? (toly.
fttOMk CMllaguet. r4xc wdal sappert. <fnpl«?tr cwpctaivyn. velf-reotjvxtjea
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vuhianccv, anvix «* lw?*hh fedbiicx. jpvtwnw vuppv>n «c|
:<
I
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IN THE LAST MONTH DIDTOO FACE ANY
Wno...
SYMPTOM^ILINESS THAT CAUSED YOU
am
SRTMHCANT DISCOMFORT?
______________
IF YES, DESCRIBE ALL THE IUNESSES YOU FACED IN THE LAST MONTH
Ourmhik CWtfs arc a* followt: I tW>' cunM; 2* penally lured. J n*> imfirmweM l»4 toga to aitotNcr 4actor; 4 no
iffijwuw Ito further Ktion.
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immc<d«ncl>: 2 - i«xt rc^ Br abostt two &
thm hM«i
hM u> wfc 3- mk MlfW oft 4
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than I 4ay.
oo
SYMPTOM
0I.DXW
WH AT DID YOU 00?
WK’OME
EITECT
ON
WORK
65
1B2?
Oil) VOL MM I A IKK TOR OR ANY OTHIR
HEALTItt-ARE: PROFESSIONAL IN THE LAST
MONTH'*
MS NO
II YES. DESCRIBE ALL YOUR VISITS
js.NO
RUSON
given
TYFEOI
DOCrORHEALTH
FACILITY
TOTAL
COSTON
OUTCOME
RS) .....
J
ms aw w;i«
2029
HOW OFTEN DO YOU AND YOUR FAMILY
MEMBERS EAT THE FOLLOWING FOOD ITEMS:
DAILY. WEEKLY. CXXAMONALLY. OR NEVER?
DAILY WEEKLY OCCASIONAUY NEVER
12
3
4
A> MttXCVRD
Bl Pt’lSl^BEANS
C) DARK GREEN LEAFY VEOETADOS
m FRUITS
E) EGGS
Fl FISH
G) CHKXEN MUTTON
HI FRIFDHwmS
II FAST FOOD
n cowmiNKs
w
2031
2032
HOW MANY TIMES A DAY DO YOU EAT HOME
amm>FooDt
DO VOL' OR ANY MEMBER OF YOUR FAMILY
USE TOBACCO?
WHAT FORM OF TOBACCO B ®5?
I
H.
Ill
IV.
E
V.
VI.
VIE
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INmiATFREXXl'FM’YT
TWICE
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YES’NOWNYKNOW
H.
in
tv.
2033
AU THREE TIMES
I
E
IE
BIDI
aGARETTES
HOOKAH
GOTKHA FAAN MASALA WITH TOBACCO
KHAIM
PAN WITH TOBACCO
SNUFF
OTHER CHEWING TOBACCO
ALMOST EVERY DAY
ABOUT ONCE A WEEK
LBS THAN ONCE A WEEK
66
ANNEXURE 2
Interview Guide
1. Describe your role and how long you have been in this job.
2. What are the entitlements and benefits provided to the pourakarmikas?
3. What are the type of pourakarmikas and their job responsibilities?
4. What are the common health problems that they face?
5. What are the safety measures provided by the BBMP?
6. Are there any benefits, leave policy, retirement policy, pension, salary and other benefits?
7. Are there any dedicated health personnel for pourakarmikas? Are there any dedicated services
for the pourakarmikas?
8. What are the challenges you face?
9. Do you have any other comments?
Position: 345 (9 views)