“Minding the Gap”

For a city that seems so overburdened by poverty, sanitation issues, and unfathomable human density—hope springs in the constant movement of people, rickshaws, traffic that enliven the streets and the numerous NGOs “minding the gap” of disparities. The past week in Mumbai can only be described as life defining—although I am not quite sure how drastically yet.  Our class was able to meet with a number of NGOs supplanting an under resourced government sector to increase health access to residents of both the slum and the tribal rural sector.  The dedicated “change agents” we have met at Ameri-Cares, SNEHA and Impact India were as inspiring individually as the profound work they do.  Mumbai did demonstrate the starkness of income disparities—however, an inchoate middle class and a renowned sense of dedication in redeveloping and reinvesting in India—by Indians offer both insight and encouragement. 

The Slums

We learned that 50 percent of Mumbai’s population resides in slums where a confluence of dense, unsustainable growth, lack of sanitation services and overcrowded conditions create a melting pot of public health issues.   However, 90 percent of slum dwellers own a cellphone-an encouraging medium for innovative health interventions. 

We were able to visit both the Chandivili and Chembur slums in Mumbai.  Our first introduction to the slums came on our third day when we visited the Chandivili slum in the Andari area with Ameri-Cares, a global NGO. With a staff of just 25 consisting of doctors, data-entry personnel, drivers and pharmacists—Ameri-Cares provides prescription drugs to the underserved, responds to natural disasters and administers mobile medical units and camps to the slums in Mumbai. The prescription drugs are donated by major pharmaceutical companies globally. They also have a mobile van and health center that provides access to a doctor and basic preventative services every 15 days. Although very young--Ameri-Cares started in Jan 2011, a line of mothers waited outside both health offices in the Chandvili and Chembur slums indicating a reliance on their service. The doctors said they often see between 100-150 patients in the few hours they are in the slums and the most common illnesses are diarrheal disease and dysentery.  



Lisa mapping in Chandivili

 The Ameri-Cares personnel asked us to map the Chandivili slums by counting doors as the baseline for a household census to be completed later. This project enabled us to develop an understanding of the intricacies density of the slums. Every time we walked down a street, invariably there were at least 2 or more narrow streets branching off of it—cramming over a million people into a few kilometers of space. It also gave us an opportunity to see a “higher end” slum on the hierarchy of slums,   where the streets were paved and garbage was contained. It was also typical to find a house with a television and satellite dish.  I was surprised at the micro-economy in Chandivili from tailors to bakers and welders.  Both communities also contained a number of temples and mosques as well as missions. Apparently, residents of the Chandivili slum may have jobs in the civil service, but don’t leave the slum because of the community. 

Chembur slums



Our experience at Chandivili was completely different from our time at the Chembur slum.  In order to understand the mobile health services program, a few of us returned with Ameri-Cares workers the next day to observe their program in the community. We arrived to a densely packed community interwoven by over 100 open sewer drain ditches covered by slobs of concrete.  The entire community smelled of sewage and garbage surrounded the community.  I could not believe the dire and poor sanitary conditions in this community.  Again, I found myself asking why these conditions persist in 2012?  Our group also attracted a lot of attention from the children who followed us throughout our entire visit and it was incredibly sad to know that they lived in a community that perpetuated diarrheal diseases and other easily preventable health conditions. A simple sanitation program and some planning would make the world of difference. 



Dr. Patel from Ameri-Cares in Chembur



Hope



While personally, the entire environmental context intermixed with the abject poverty was exceptionally disconcerting, it was particularly inspiring to witness two unsung heroes—Dr. Patel and another Ameri-Cares worker diligently assist the line of women and children gathered in front of the small borrowed space utilized as a mobile clinic.  I was amazed at the constant line present in front of the mobile health center and impressed at the dedication of Ameri-Cares to make a difference in slum communities like Chandivili and Chembur. 

Another hopeful organization “minding the gap” due to insufficient government resources is the Society for Nutrition, Education and Health Action, SNEHA.  We were introduced to a handful of AMAZING women including founder Dr. Fernandes all committed to administering real change in health poor health outcomes among slum residents. SNEHA—a 12 year old non-governmental organization ascribes to work with community partners, “within the existing system” to increase nutrition among mothers and children and reduce violence against women (approximately 45 percent of Indian women marry before 18 years of age).  



Children of Chembur slum 



Maybe it’s because I am a public health student but, SNEHA is particularly impressive to me because they use data and conduct research to inform their intervention strategies. We were able to see three programs administered in Dharavi slums—the second largest slum in Asia (Karachi house the largest).  I was able to attend the malnutrition program and met with a community health worker who feeds babies from 0-3 who are severely underweight and malnourished.  Dipali, the community health worker discussed the delicate balance she navigates when discussing malnutrition and poor home conditions with families during home visits. 

Additionally, SNEHA also engages in capacity building while simultaneously challenging gender roles by empowering women residing in the slum to learn how to sew.  A small program on the cusp of being scaled-up employs women to make patchwork quilts out of donated scrap fabric. We learned that the venture has been so successful the husbands are now looking after the children while the women work. 

The resilience of the people living in the slums and the commitment of NGOs like Ameri-Cares and SNEHA bring hope to an otherwise overwhelming reality.  Although I believe the government should play a more active role in solving the sanitation issues and improving health care access, these organizations offer insight into what works best on the ground.