Environmental Problem and Chronic illness among the urban poor: An in-depth look at the urban poverty
Chapter One
Introduction
1.1 Introduction
Environment and health are always significant in poverty research both in rural and urban areas. However the focus of this research will be on urban poverty as it is relates to health and environment. In policy implementation about urban poverty, relation between environment and health is important and contemporary issues for analysis. In poverty research, ill health is frequently considered as a key indicator of poverty. Poor nutrition, inadequate sanitation and water and insufficient access to healthcare are identified in many studies as the underlying causal factors responsible for illness. In the urban settings of developing countries the combined effect of old pathogens and new health risks including environmental pollution and stress means that disease burdens are particularly high among the poor (Pryer and Crook, 1998; Harpham and Stephens, 1992; Seager, 1995; Wratten, 1995 Brockerhoff and Brennan, 1997). The title of this thesis is ‘Environmental Problem and Chronic illness among the urban poor: An in-depth look at the urban poverty’ which is an attempt to analyze several issues; first, to understand the relation between environment and chronic illness among the urban poor. Second, discussing impacts of chronic illness caused by the environmental reality on the poverty situation among the urban poor and through the discussion to find out the relevance of chronic illnesses as a particular indicator in greater health issue in urban poverty. Chronic illness has been identified here as a distinct indicator which is less recognized in existing perimeter of the concept of health. The fieldwork of the research has been carried out in 2 slums in Dhaka city.
1.2 Theoretical Background
As a concept, urban poverty has been emerging as a critical issue which is different from the previous conception of poverty where the emphasis was on rural poverty. Similarly environment and illness are contemporary burning issues in development discourse and also is being studied in two major field of anthropology; environment and medical anthropology. But these terms are not invariable or universal; rather, debate about conceptualization of these terms is persisting both in academic and development arena.
1.2.1 Conceptualization of poverty
Green (2003) argued that, “poverty” is needed to be analyzed as a research problem; as an analytical category, and as a social experience within social science. Green argued “apparent disengagement of anthropology from the problem of poverty should not be read as evidence of that discipline’s irrelevance for poverty research or for development studies more generally, but rather as a necessary caution concerning the study of poverty”. Moreover, anthropological studies have enthusiasm for illustrating social relations and dimensions of various relations, which are being traced as the responsible of inequality (Dumont 1970; Douglas 1991; Hart 2001)[1]. Green concluded that, therefore, poverty should not be defined from the ways through which goods and means are prioritized and policies for reducing poverty are taken.
In Poverty and Famine (1981), Sen also questioned the presumptions ideas of poverty. He said, “In some traditions, this is done very simply be just counting the number of the poor, and then expressing poverty as the ratio of the number of the poor to the total number of people in the community in question” (Sen 1981:10). Therefore, conventional measurements of poverty relate household per capita income or expenditure is unable to reflect the subjective perceptions of well-being or ill-being (Greely 1994), and “there is no particular reason to suppose that the concept of poverty must itself be clear-cut and sharp” (Sen 1981: 13).
Anthropological studies of poverty have shown that people’s own conceptions of deprivation often differ from those of professional experts. Great value is attached to qualitative dimensions such as independence, security, self-respect, identity, close and non-exploitative social relationships, decision-making freedom and legal and political rights. More generally, there has been a widening of the debates on poverty to include more subjective definitions such as vulnerability, entitlement and social exclusion. These concepts have been useful for analyzing what increases the risk of poverty and the underlying reasons why people remain in poverty. Vulnerability is not synonymous with poverty, but refers to defenselessness, insecurity and exposure to risk, shocks and stress. Vulnerability is reduced by assets, such as, human investment in health and education; productive assets including houses and domestic equipment; access to community infrastructure; stores of money, jewelry and gold; and claims on other households, patrons, the government and international community for resources at times of need (Chambers 1995, cited by Wratten 1995). Social exclusion is seen as a state of ill-being and disablement or disempowerment, inability which individuals and groups experience. It is manifested in ‘patterns of social relationships in which individuals and groups are denied access to goods, services, activities and resources which are associated with citizenship’ (ILO 1996). Robert Chambers (2006) argued that development professionals represented the expressions of “our” education, training, mindsets, experiences and reflections.
1.2.2 Context of Urban Poverty
In greater poverty situation, urban poverty is an emerging issue. As a concept, urban poverty has different dimensions. There is no agreement or consensuses on how best to define and measure urban poverty. However, two broad complementary approaches are prevalent; these are economic and anthropological interpretations of poverty. Conventional economic definitions use income or consumption complemented by a range of other social indicators such as life expectancy, infant mortality, nutrition, the proportion of the household budget spent on food, literacy, school enrolment rates, access to health clinics or drinking water, to classify poor groups against a common index of material welfare. Alternative interpretations developed largely by rural anthropologists and social planners working with rural communities in the Third World allow for local variation in the meaning of poverty, and expanded the definition to encompass perceptions of non-material deprivation and social differentiation (Wratten 1995; Satterthwaite 1995a).
Social science research has made important contributions to understanding the lives of the poor and homeless in many pares of the world. From both a theoretical and a practical perspective, critical medical anthropology, this as we have seen takes into account the political and economic circumstances of health and disease is essential to a clear understanding and documentation of tie needs and voices of the majority of the world’s population (Singer, Bear and Susser: 1997).
In some ways homelessness or informal settlements, squatters settlements, and poor people without shelter in the poorer countries of the world derive from processes akin to those experienced by the wandering poor of early industrial Europe. In other ways the experiences are very different. In formal settlements, lack major public health foundations. They lack sewage facilities and electricity. They often lack paved roads and transportation as well as running water and drinking water.
Rachel Mashika (1997) suggested, conceptualizing urban poverty as a separate category is also problematic because of different yardsticks for defining urban in different countries. Many point to the important connections between the two, as household livelihood or survival strategies have both rural and urban components (Satterthwaite 1995). Baker (1995) and Wratten (1995) illustrate this point in terms of rural-urban migration, seasonal labour, remittances and family support networks. Baker (1995) illustrates how urban and rural households adopt a range of diversification strategies, by having one foot in rural activities and another in urban. It shows that urban poverty has a different context to understand.
1.2.3 Environment; ‘Contemporary Burning’ issue effecting Urban Poverty
The impact of environment on human activity is always an important issue in trends of anthropological theories which was discussed many times by environmental anthropologist. In recent time, globally, environment is a burning issue related to urban poverty. Environment and poverty are also significant interest area for anthropological research in particular and development research specifically.
In common usage, ‘environment’ refers to non human influences on humanity. Like ‘nature’, it is shorthand for the biophysical context, the natural world in which we live. According to Encyclopaedia of Social and cultural Anthropology (1996) environment refers not just to biophysical context, but to human interaction with and interpretation of that context. The development of theory and ethnography of human-environment relations can contribute significant opportunities for applied anthropology. Indigenous environmental knowledge promises to be of great importance in improving environmental management and by enhancing its status among planners, anthropologists can promote participatory development.
The concept of environment is too difficult to define. The word ‘environment’ is a vast one: ranging from microbic action to the size of world population (Nasreen, 2000). According to the Webster’s New Collegiate Dictionary environment has been defined as “the aggregate of all the external conditions and influences affecting the life and development of an organism”. The aim then, with either individual organism or communities, is to distinguish between factors arising from outside the system and factors inherent in the system itself. This sounds simple enough, but in practice the distinction between organism and environment is not always easy to make (International Encyclopedia of Social Sciences, 1984:91).
The living environment in the slums such as; poor sanitation, cramped housing, absence of waste removal and inadequate ventilation are reflected in high levels of diarrhoel and respiratory infection (Kabir, Rahman, Salway and Pryer 2000). More immediate relevance to the themes of urban housing, water and sanitation on the one hand, and cities and climate change on the other, is what has been termed the urban environmental transition. This involves a shift from local environmental health burdens that impact health directly towards global environmental burdens that impact health through their effects on life-support systems (McGranahan, 2007; McGranahan et al., 2005; McGranahan, Songsore and Kjellén, 1996).
1.2.4 The Concept of Chronic illness: Emerging problem
Theoretically chronic illness is not a name for any particular disease but rather a general term describing the length of duration of a disease’s symptoms. A chronic illness is basically an illness that has a long term effect on the body. Some chronic illnesses, or the tendency to contract them are hereditary, and some are environmental.
In many literatures of biomedicine, there is no universally accepted definition of disease. Like many theoretically important concepts, “disease” is essentially left undefined and is used in ambiguous ways. On the other hand, by definition, perceptions of illness are highly culture related while disease usually is not. In the Western World, people usually do not make a distinction between illness and disease. These two terms seem to mean essentially the same thing and are often used interchangeably. However, it is important to define illness and disease differently when considering some non-western cultural traditions. Disease is usually an objectively measurable <href=”#pathological”>pathological condition of the body. In contrast, illness is a feeling of not being healthy and normal. Illness may in fact, be due to a disease. (http://anthro.palomar.edu/medical/med_2.htm: 2006). Therefore illness refers to individual ‘feelings’ of ill condition of health and disease refers to a definition of illness by some ‘experts’ like pathological diagnosis or doctor’s view.
In Medical Anthropology: Contemporary theory and Method, Sargent and Johnson (eds.1996) mentioned that, “Health,” of course, is so notoriously difficult to define that the World Health Organization’s (WHO) Utopian phrase, “a state of complete physical, mental, and social well-being,” has little use for those who wish to measure health. Medical social scientists have often made the distinction between disease and illness. In this case, disease refers to a set of objective, clinically identifiable symptoms, while illness refers to an individual’s perception of those symptoms. This perception is what motivates the individual to seek medical care or to assume the sick role (Mechanic 1968).
Kleinman, Eisenberg and Good (1978) mentioned that, eliciting and providing accounts of explanatory models of illness are certainly a means of analyzing patients understandings of their condition and serve as an entrée to teaching clinicians to elicit the “native’s point of view” during their clinical work.
Heurtin and Becker (1993) argued, chronic illness has received little attention in medical anthropology as a topic of research. The study of illnesses considered to generate important questions about the ways in which illness is conceptualized. Here some important influence are; biomedical perspectives on illness management, the role of medical treatment, and the expenditure and accessibility of care. As they said,
“Anthropological studies of such conditions can be found, for the most part, within the broader literature on illness experience; with a few exceptions, however, these works do not examine the role of chronicity in experiencing an illness. Sociology, in contrast, has developed a considerable literature on how chronic illnesses are understood and experienced, including how individuals manage daily life, the effects of chronic illness on identity, and the effects of interactions between chronically ill persons and the health care delivery system. While a sociological approach emphasizes the effects of societal structure on illness, an anthropological approach emphasizes a cross-cultural, comparative approach that enables anthropologists to question basic assumptions about health and illness” (p: 282).
According to the web medical dictionary[2] chronic illness refers an illness that persists for a long period of time. The term “chronic” comes from the Greek chronos, time and means lasting a long time. By the definition of the U.S. National Center for Health Statistics, a chronic illness is one lasting 3 months or more. In ancient Greece, the “father of medicine” Hippocrates distinguished diseases that were acute (abrupt, sharp and brief) from those that were chronic. This is still a very useful distinction.
In the section of medicine in wikipedia:the free encyclopedia, it is mentioned that, a chronic disease is a disease that is long-lasting or recurrent. The term chronic describes the course of the disease, or its rate of onset and development. A chronic course is distinguished from a recurrent course; recurrent diseases relapse repeatedly, with periods of remission in between. As an adjective, chronic can refer to a persistent and lasting medical condition. Chronicity is usually applied to a condition that lasts more than three months. The definition of a disease or causative condition may depend on the disease being chronic and the term chronic will often, but not always appear in the description.
Living and working environment can be a reason for chronic illnesses among urban poor. To explore the state of chronic illness in urban settings of Bangladesh, I can refer the paper, Water, Sanitation and Hygiene Promotion, which was A civil society submission to the Government of Bangladesh (2003). In a section of this paper explained:
“The disparity between demand and supply of water and sanitation services is worst in the urban slums of Dhaka, only 16% of the population in urban slums uses safe water, only 13.5% sanitation coverage in metropolitan slums. The external environment in low income urban areas is heavily germ-ridden. This translates into acute, chronic illnesses and, too often, death. Those surviving suffer from stunting and wasting due to malnutrition caused by repeated diarrhoeal attacks and intestinal worm infestations. This is a major contributing factor to poor health. The situation will deteriorate if proactive interventions are not undertaken in the short to medium term” (P: 12).
Stating the chronic illness of urban settings in Bangladesh mentioned above, we found that, some illnesses like diarrhea caused by environmental factors can be turn into ‘chronic’ illness by repeated attack and intestinal worm infestations. This refers the consequences of illness to a ‘chronic’ state and reasons behind it.
1.3 Research objectives and questions:
This thesis is aiming to explore the relation between chronic illness and environment among the urban poor as a problem which is affecting their poverty situation. There is no doubt about the impact of environment on health conditions among the urban poor but for a long time health issues are considered in some limited arena in urban poverty reduction initiatives; such as reproductive health, child and some adult diseases . Present research is an attempt to enhance the concept of health by elaborating the concept of chronic illness caused by the environment. Conceptually environment has a larger boundary in terms of its context which includes global climate change also; which can be a broader research topic under the title of environment as a whole. Whereas in this thesis, research topics is contextualized in to much more local perspective like living surroundings and working condition of poor people in urban area. In this research the context of ‘environment’ has been focused in two senses-
1) Residence environment; refers to infrastructure of living in slums like house patterns, water, sanitation, streets, waste management etc.
2) Working environment; refers to the condition of existing circumstances where people are doing their job or economic activity to earn.
In this research chronic illnesses referring to diverse type of diseases and illness those are most of time considered as very normal illness of household members but suffering from these illnesses chronically all over the year because of both living surrounding and working environment. And most of the time these illnesses are defended by home remedy. Hence the relationship between environment and chronic illnesses is most important here; therefore objectives of the research are as follows:
1. To find out the relation between environment (residence and working) and chronic illness among the urban poor.
2. Exploration of the perceptions and healthcare seeking behaviors among the urban poor by considering chronic illnesses.
3. To identify the impact of chronic illness and environment and among the urban poor.
1.4 Rationale and Justification of the Research
Homelessness and poverty are an international crisis. Bangladesh, with a population of 147.4 million is one poorer country in the world; with an estimated 3.4 million people live in some 5000 slums of its capital city, Dhaka. In 2010, the population of the city of Dhaka has been projected at 17.6 million people, with up to 60% in the slums. In Bangladesh, Poverty Reduction Strategy Paper (PRSP) places poverty reduction efforts firmly in rural areas. Though urban poverty is significant from last few decades but in last 50 year’s poverty reduction strategies and programme, urban poverty was not addressed properly (Ellis and Biggs; 2001). Urban poverty was notably excluded from the draft PRSP, and only incorporated into the final PRSP after campaigning from Local Government Engineering Department (LGED) and other concerned stakeholders. However, its inclusion into the PRSP which appears as an afterthought rather than as a serious objective is not sufficient.
But many critiques has been raised about PRSP that, it is not explicitly a policy for poverty reduction, the strategies prioritized within it provide direction and guidance in the selection of government policy and budgets[3]. Consequently, as well as being inadequately reflected in the PRSP, urban poverty has also been neglected in policy and spending. No formal policy on urban poverty exists, and no government funds are earmarked for the urban poor. In their absence, and given the existing budget constraints of municipal governments, local governments struggle to address urban poverty (Nicola Banks, 2008). Though state poverty policy is inadequately addressing urban poverty but in recent years NGO issues are working for it.
Among the urban poor environment and health issues are always important; but in health arena chronic illnesses are considered as ‘very normal’ form in perception of both poor people and development practitioners. By this way, some illnesses those are chronic among urban poor have been ignored as an indicator affecting their household economy. For example:
“Increasing recognition of ill health as a barrier to economic advancement and poverty reduction (both at the micro and macro levels) is reflected in policy directions which emphasized investment in human capital. However, relatively little is yet known about the experience of ill health among the poor or what the cause of this chronic illness is (World Bank, 1990; 1993; DFID, 1999a; 1999b)”.
Early investigation into the impact of ill health on the economic circumstances of households and populations tended to suggest little impact (Pryer and Crook, 1998; Harpham and Stephens, 1992; Seager, 1995; Wratten, 1995 Brockerhoff and Brennan, 1997). In particular, they failed to examine adequately the direct and indirect effects of illness episodes and the protective strategies which may be employed in high morbidity settings and which may have negative implications for economic advancement and well-being (Over et al, 1992). In Bangladesh a few studies have highlighted the significance of ill health as an impediment to security among the poor (Pryer, 1993; HKI-Bangladesh and IPHN, 1996). Besides this, the causes of chronic illness are identified; that is the poor and dirty residence environment in slums in city. More over working environment is also affecting the health status and household economy of urban poor people, such working environment are, as an example congested and dusty working place. Here in present research relation between chronic illness and environments and impact of ill health/chronic illness on urban poverty has been analyzed.
About urban poverty, most of the researches have been carried out by non government research institute and NGOs. Moreover no detail or analytical research has been found about the relation between chronic illness and environment (residence and working). In some recent years many NGOs are working for urban poverty reduction but they are focusing on broader issues like health, sanitation, education etc. Most important thing is that, there are not many literatures in both academic and applied field about chronic illness and environmental impact on urban poverty. Too small number of literatures and research papers I have found but those literatures did not focus chronic illness and residence and working environment of urban poor people. In all research papers that I reviewed, health means morbidity, reproductive health and child diseases. But there is a serious ignorance about some chronic illnesses like fever, cough and cold, headache and few others; those are usually treated as very normal illness.
So, urban poverty should be more contextualized and health issues deserve more concentration. Chronic illness, however, is more critical to explain from urban Poor’s point of view. Urban poor people may define chronic illness as very normal disease or habitual because of their different perception of illness and diseases. If we want to recognize chronic illness more specifically within health issue, then we should consider poor people’s perception about the relation between environment and chronic illness, which was ignored or overlooked earlier. Environment, as an indicator of creating chronic illness which is a barrier to livelihoods, should be prioritized before making policy and implementing health projects for the urban poor. Therefore, focusing people’s perceptions of chronic illness and environment may provide a dimension of urban poverty, so that, there may have possibilities to rationalize and reorganize of the categories those are used for measuring urban poverty.
1.5 Structure of the Thesis:
Structure of the thesis contains eight chapters. Among them, Chapter one reveals the theoretical discussion, objectives, rationale and relevance of the research. Chapter two will restrain the literature review. Research methods and tools, used in this research will be discussed in chapter three. Description of the research context and socio-economic background will be discussed in chapter four. Chapter five will describe about environmental factors related with chronic illness. The perceptions of chronic illness and health seeking behavior among the urban poor will be analyzed in chapter six. In chapter seven, impact of chronic illness on poverty situation and coping strategies will be elaborated. Finally chapter eight will conclude the research findings.
Chapter Two
Literature Review
Literatures on the relation between chronic illness and environment are rarely found. This is because, many research on this specific issue has not been conducted in the past. Though a large number of literature on health, illness and environment issues can be sorted out, but particularly in Bangladesh, addressing chronic illness (as I am trying to define some normal illness as chronic in terms of duration all over the year), in terms of relation with environment and their affect on urban poverty are not studied well; lack of literatures are proving the fact. I have selected literatures of other countries; those are concerning about environment and chronic illnesses among urban poor. Literatures have been discussed in two section; firstly, literature from other countries those are representing global context of chronic illness and environmental problem of urban poor. Secondly, in Bangladesh context literatures reviewed according to the close relevance with health, illness and environment issues. It is because, there are thousands of reports, articles and researches about this, but as there are very few about the relation between environment and chronic illness, I have selected only more related literatures. Among these, some literatures addressed environment and health issues generally and some are partially related to this research.
2.1 Global Context of Chronic illness, Environment and urban poor:
Haddad, Ruel and Garrett (1999, 2) suggest that: “Many analysts believe that the locus of poverty and under nutrition is gradually shifting from rural to urban areas.” In their own study, they disaggregate data between urban and rural areas for eight countries, each with information for two points in time, and conclude:
“In five out of the eight countries, the absolute number of urban poor and the share of
poor people living in urban areas is increasing over time (Bangladesh, China, Ghana,
India and Nigeria). For seven of the eight countries the share of poor people in urban
areas is increasing” (ibid, 8).
However, most analysts believe that the locus of poverty is shifting from rural to urban areas. During the late 1990s, there were at least four figures for the proportion of Kenya’s urban population who were poor, ranging from 1 to 49 percent.[4] In the Philippines, in 2000, the proportion of the national population with below poverty line incomes was 12 percent, 25 percent, 40 percent or 45–46 percent, depending on which poverty line is chosen. In Ethiopia, the proportion of the urban population with below poverty line incomes in 1995/96 could have been 49 percent, 33 percent or 18 percent, depending on what figure was used for the average calorific requirement per person.
Satterthwaite (1997 and 2001, 146) summarises the works of a number of authors to argue in favor of an even broader interpretation of poverty that includes measures of exclusion. He identifies eight aspects of urban poverty: 1. inadequate income; 2. inadequate unstable or risky asset base; 3. inadequate shelter; 4. inadequate provision of public infrastructure; 5. inadequate provision of basic services; 6. limited or no safety net; 7. inadequate protection of poorer groups’ rights through the operation of law; and 8. poorer groups’ voicelessness and powerlessness. There is a missing to deal with health issues particularly illnesses in his work which was mixed up with the fifth category; inadequate provision of basic services. But, normal illnesses those are chronic and caused by environments is globally an emerging problem in urban settings which is reflected by World Health Organization.
World Health Organization focused its World Health Report on risks to health where only two environmental risks that figured out in their top ten risks. These are unsafe water, sanitation and hygiene and indoor air pollution (WHO, 2002). It is estimated that in the year 2000, unsafe water, sanitation and hygiene accounted for about 1.7 million deaths which is 3.1 per cent of all deaths and the loss of 54 million disability-adjusted life-years (Ezzati et al., 2002; WHO, 2002). In the same year, indoor air pollution accounted for an estimated 1.6 million deaths and the loss of 39 million (Ezzati et al., 2002; WHO, 2002). Most of this mortality and disease is linked to diarrhoea in the case of unsafe water, sanitation and hygiene (Cairncross and Valdmanis, 2006), and lower respiratory infection in the case of indoor air pollution (Smith and Mehta, 2003).
Brown, Inhorn and Smith (1996), in their article “Disease, Ecology and Human Behaviors” showed that, numerous occupational groups have been shown to be at higher risk of various diseases because of their exposures to workplace. These include miners, agricultural laborers exposed to various pesticides, and workers in cotton mills, dry cleaners, and the reinforced plastics industry, to name only a few. In addition to the risk of toxic exposure, workers may suffer the physical trauma of manual labor that is repetitive and unceasing. They also argued that, disease is often defined by what it is not. Disease is generally seen as a failure of normal physiological activities and a departure from a state of health. But such a definition is less informative. The problem is that within this definition is a concept of “normal.” Yet it is clear that normality must be considered as culturally constructed; for example, conditions that have been considered as normal in particular populations include persistent diarrhoea (Desowitz 1981), malaria (Ackerknecht 1945), the bloody urine of schistosomiasis (Heyneman 1979), and the skin discolorations of pinta (Ackerknecht 1943). They also argued, When defining disease, it is useful to compare the conceptions of the layperson, the biomedical specialist, and the disease ecologist. Most people, even in complex societies, conceive of diseases as invisible entities “out there,” that can attack victims and cause sickness, pain, loss of vitality, and even death. Although diseases are usually named, they generally cannot be controlled by ordinary individuals. From the emic perspective of the patient, there is little difference between a disease caused by a “germ” and one caused by evil spirits or other supernatural agents. In either case, the sick person may be a completely innocent victim of the disease (as in most pediatric cases) or may have partly partum taboos, smoking cigarettes). Their central argument was that, for most people, the large number of unknown diseases “out there” makes the world a dangerous place. People can attempt to prevent “catching” a disease by avoiding contexts where they are exposed to pathogenic agents or by avoiding conditions where they might be more likely to have diseases “sent” to them.
In their paper Heurtin and Becker (1993)[5] said, health conditions that can be managed but not cured, chronic illnesses have ongoing or periodic symptoms that interfere with daily life health conditions that can be managed but not cured, chronic illnesses have ongoing or periodic symptoms that interfere with daily life.
Bury (1982, 1988, 1991) argued, chronic illness as a ‘critical situation’ (Giddens 1979) for which no prescribed role is available but Chronic illness disrupts lives, relationships, and identity. Chronic illness necessitates a response that is practical, social and reflexive.
Paulo and Nair (2003) described the events faced by urban poor households in Lucknow, India and the responses of the household in the face of these events. Using household and individual data collected in 2002 from 12 slum settlements, the authors found that certain events, such as illness and social and religious spending, are more frequent than others and that some groups, characterized by gender of head of household, community and economic status, experience certain event types more than others. It also found that some less frequent events may be very burdensome due to their high severity. Responses to common event types exhibited a pattern. Households reduced consumption, used savings and took loans much more frequently than other options, across event types. Variations in responses were identified by event type and severity and economic status. The results illustrate the need for both protective and promotive interventions to improve livelihood security among the urban poor.
Smith and Ezzati (2005) identified three types of environmental risk creating health risks and attributed disease burdens among the urban poor. These were:
- Household environmental risks – poor water, sanitation and hygiene; indoor air pollution from solid-fuel use; exposure to malarial mosquitoes;
- Community environmental risks – urban outdoor air pollution; lead pollution; occupational risks; road-traffic accidents;
- Global environmental risks – climate change.
The authors found that in particular these risks are the major causes of increasing chronic diseases among the poor urban dwellers.
From the perspective of participatory action research approach Robert Chambers (2005) in his paper “The many dimensions of poverty” he identified the concept of poverty as “multidimensional deprivation”. Some arguments of him can be useful to the understanding of urban poverty. Chambers agreed with Narayan (Narayan; 2000 quoted in chambers paper) and criticized the existing poverty measurement including economist and anthropologist. He suggested that poverty should be located from its multi dimensional reality as poverty has many dimensions of deprivation. From his many indicators here we can recognize two dimensions of poverty for urban poor and their illness. One is ‘Places of the poor’ and the other is ‘The Body’. He argued, the places where poor people live suffer combinations of isolation, lack of infrastructure, lack of services, crime, pollution, and vulnerability to disasters like drought, floods and landslips. About urban settings he mentioned,
“Stigma of urban place can mean that place of residence must be concealed or dissembled when applying for a job. Inordinate amounts of time may be required for obtaining basics like water. The Chronic Poverty Report 2004-05 devotes a whole chapter (CPRC 2005: 26-35) to “Where do chronically poor people live?” and does a service by describing and analysing spatial poverty traps, their ecological characteristics, poor infrastructure, weak institutions and political isolation. Place, whether rural or urban, as an interlocking dimension of deprivation is so obvious that it is strange that it has not received more prominence. It should be harder to overlook now that it has been named”.
In the section of The body he said, the central importance of the body to most poor people has tended to be under recognized. To explain the importance of body for poor people the said,
“The body is more important to people living in poverty than it is to professionals. For many, it is their most important asset. But it is at the same time vulnerable, uninsured and indivisible. It has often been weakened by life experiences. It is exceptionally exposed and vulnerable to hard and dangerous work and accidents, to violence, to sickness, to lack of nutrition, overwork and exhaustion. With an accident or illness it can flip suddenly from being main asset to liability, needing payment for treatment and having to be fed and cared for. It is a recurrent finding that many falls into bad conditions of deep poverty because of what has happened to their bodies. Yet in general, the priority to poor people of quick, effective and affordable treatment has been under-recognized by professionals”.
Hence, Chambers argument is important for evaluating the environment and illness situation; the coping strategies with chronic illness among the urban poor.
2.2 Context of Bangladesh:
In their article “The Interrelationship between Poverty, Environment and Sustainable Development in Bangladesh: An Overview” Nasreen, Khondokar, Hossain and Kundu (2006) argued that, poverty alleviation and environmental protection are in harmony to reinforce sustainable development. They concluded that Environmental issues need to be dealt with the participation of all concerned, with the government and citizens at the relevant levels. To them, unfortunately this fact is almost absent in Bangladesh. They also said that a number of factors are involved in this failure which includes lack of good governance and political institution, corruption, western development model, unplanned use of natural resources, defective industrialization and urbanization process, social disparity, exploitation, inequality etc.
Hossain(2003), in his paper Urban Poverty And Household Strategies In Dhaka City, Bangladesh argued that, the urban poor adopt strategies through their household such as; their economic activities, household expenditure, social networks, rural-urban ties and community organizations to survive in the city as they have limited access to existing economic and social systems. He discussed about some strategies of urban poor to survive in city. He mentioned that, entering more household members into the workforce is the main survival strategy of the urban poor and most of the poor (56.8%) who live in low expenditure housing spend a certain amount of their income on housing. They also spend a small amount of their earnings on clothing, medicine, education and other incidentals. The urban poor mainly buy food items like rice, pules, potatoes and vegetables at a low expenditure from local retail shops. They sometimes buy bad quality fish from local fish-markets. Moreover, they cannot afford expensive items like meat, milk and fruit. Importantly he identified that, Dhaka’s urban poor have very limited access to the existing health care facilities. The majority of urban poor get their medicine from pharmacies without the consultation of trained physicians. In most of the households traditional forms of medicine (folk medicine) are used along with modern forms of medicine. In this literature, discussion about the strategies of livelihood among the urban poor was the main concern and author mentioned about major environmental factors and health facilities are available in slums. Still, particular link or relation between environment and illnesses; especially normal chronic illnesses like fever, cough and cold, headache, waist pain etc were not studied well. Present thesis is concerning about these strategies but more specifically coping with normal chronic illness those are caused by their living and working environments which affect their livelihoods.
In their paper, Health and Social Conditions in the Dhaka Slums[6], Podymow, Turnbull, Islam and Ahmed (2002) showed that, most respondents (89%) of their study did not feel that they lived in a hygienic environment, and 93% felt that the slum had lead to disease or ill health in their families. They identified reasons for poor health included rheumatic fever, tuberculosis, leprosy, abscess, epilepsy, disabled hand or leg, kidney disease and non-specific descriptions. In their study, health care providers were found as medical doctor, homeopathy, “quack” (traditional medicine) and NGO clinics. They also recognized some major causes like, living conditions, prevalence of illness, access to clean water and latrines, availability of health services, nutrition and education. Finally they concluded that, at any given time, 30-45% of the urban poor have been reported ill. This paper identified some diseases affecting urban Poor’s health condition but they did not consider some normal illness such as cough and cold, scabies, headache, abdominal and waist pain, gastric etc. only fever they have mentioned but numerous illness can be found among urban poor people those are affecting their livelihoods and poverty situation which is focused in present thesis.
A consortium of BRAC, ICDDR, B, Johns Hopkins Bloomberg School of Public Health, and the UK-based Institute of Development Studies initiated the Centre for Control of Chronic Diseases in Bangladesh (CCCDB)[7] for better understanding of the risk factors, preventive and curative measures, and enhancing awareness among care providers and general public about chronic diseases, such as cardiovascular diseases, diabetes mellitus, hypertension (high blood pressure), and cancer. Most of these diseases are usually known to be non-communicable health problems of the elderly people. They showed that, partly due to inability to afford treatment expenditure and partly for the lack of awareness, the poor people of Bangladesh—both in rural areas and urban slum settlements—hardly seek treatment for the chronic diseases that they suffer from. Establishment of the Centre for Control of Chronic Diseases in Bangladesh with a commitment to serve the people of all socioeconomic classes is supposed to reduce this gap between the poor and the better-off in seeking treatment for chronic diseases in the country.
But In my research chronic illnesses referring to different type of illness and diseases those are most of time considered as vary normal illness of household members are suffering from; these illnesses are chronicle all over the year. A more relative research for this thesis is “sickness among the urban poor: A barrier to livelihood Security” by Kabir, Rahaman, Shlway, Pryer (2000) where they argued , it is clear that ill health acts as a chronic stress, afflicting a large proportion of households on a regular basis. They identified some normal chronic illness like diarrhea, cough and cold, fever, headache, abdominal pain etc, and also showed that, direct expenditure on health can be high, in part because of the high levels of ill-health or injury and in part because of the high expenditure of treatment. Illness may strike as a ‘shock’ that is, it may be an unexpected event that leads to economic and social crisis. Authors didn’t elaborate the causes of these illnesses among poor people in urban slums but they mentioned that, living environment is one of the major causes of it. The concept of chronic illness is being used in this thesis can be compared with illness mentioned in above study. Considering the duration of normal illnesses among poor people in regular basis these are identified as chronic illness. Besides this present research aims to elaborate environmental factors; living and working both those are not discussed in existing literatures.
Pryer, Rogers and Rahman (2006)[8] showed that, Illness may have serious consequences if it leads to a loss of income. While illness occurs in individuals the expenditure s fall on the household. Sickness in one member influences household decision regarding the allocation of financial resources. In their study they mentioned, the burden of adult ill health is highest in the poorest households and such households are at risk of being pushed into decline by episodes of adult illness. Authors argued that, when such households cope in the short term, they may need to sell assets with will reduce the household’s ability to cope with future adverse events and expenditure on illness was similar across the livelihood groups. They mentioned a perception of illness amongst the poor in developing countries is that, health is often not considered a priority by many households with income barely enough to meet the needs of daily food, shelter and clothing. Authors concluded with the finding which reveals that, the prevalence of sickness-induced loss of employment was found to be very high in the Dhaka slums, represented substantial loss of earnings and were disproportionately borne by the poorest households. More emphasis should be placed upon community health insurance and credit schemes to ease the financial burden and distress incurred following sickness induced loss of income(p:37). The study did not focus on healthcare utilization but illness were identified in general those are considered as normal illness in a previous study (Kabir, Rahaman, Shlway, Pryer: 2000) mentioned above. However, in many research it is found that, poor people in urban areas use drug stores, traditional healers or homeopaths for in the first instance, depending upon their health problem (Bhardwaj and Paul, 1986); qualified doctors are so expensive that the poor resort to this only when the condition is life threatening (Claquin, 1981).
Alam,Khanam and Hossain, (2000)[9] showed that, poor people perceive their health in terms of the absence and presence of disease which was termed as asuk/bishuk thaka or na thaka considering bad and good health. In their study authors found that, the concept of poriskhar o porichhannata (cleanliness) was quite apparent to poor people, and various expressions were used for emphasizing this. Perception about environments relating with illness can be trace with their findings, is that, “However, they were not sure whether within existing living condition; it was possible to maintain good health. Basic civic amenities, such as water, sanitation as well as proper housing were absent (P: VII)”.
In response of their in-depth interviews authors found that, people were used to wait before they sought medical treatment. They argued, the main reason was the poor economic status of the respondents and another important reason was that, at the initial stage, people considered a disease as mild, which may go away automatically. As they found a perception about illness in their study and that is opheka korle rog pake (when you wait the disease matures). About healthcare facilities authors identified the first preference for healthcare providers was nearby doctors, pharmacies due to easy access, less-waiting time, low expenditure and also their previous bad experience in public hospitals. Their paper is focusing on illness as a general concept but didn’t differentiate between diseases and illnesses. Their concentration was on perception of illness and healthcare seeking behaviors but in this thesis illnesses are different from diseases as concept and specific as normal illnesses those are chronic in every month but not a permanent disease.
In global context, literatures show the importance of interrelation among environment, health and poverty and also reveal that, particularly illness as a barrier to the livelihood among urban poor. A fact came out from the discussion is that, some normal illnesses are caused by the living surroundings and working environment, those are being chronic, such as diarrhea, fever, cold or cough, gastric etc. among urban poor in many countries. In Bangladesh context, first literature focused on the interrelation between poverty and environment in urban settings. Further two literatures are partially discussed about environmental and health conditions in slums of Dhaka city. A particular difference can be outlined between Chronic disease and illnesses from two literatures, where literature of icddr’b showed the definition of chronic disease and last literature (Kabir, Rahaman, Shlway, Pryer: 2000) showed chronic illness. Another literature (Alam, Khanam and Hossain: 2000) showed the health care seeking behavior of urban poor people which is another important topics for discussing in my research. In my data analysis of health care seeking behavior I will discuss how urban poor people are considering illnesses as their ‘very normal’ sense and not counting as diseases to be cured because of their belief system and economic condition.
Chapter: Three
Methodologies of the Research
Several methods of research technique and approach distinguish anthropology from other social sciences though it had been changed over the time and influences of development discourse. In contemporary anthropology action oriented approaches are being used also. However, in present research both quantitative and qualitative has been used to collect information from the field. The field selection and the various research tools those were used in this research are described below.
3.1 Field Selection
For the research “Environmental problem and chronic illnesses among the urban poor: an in-depth look at the urban poverty”, two research filed was selected at the northern part of Dhaka city. Field was selected in Dhaka city as because larger part of urban of Bangladesh lives in this city and I also live here. Two slums with different infrastructure were selected to compare findings by considering health related issues. Tow slums from northern part of Dhaka city were selected because of pre-experience and transport access for myself, these two slum were, Tekerbari and Raishei Tek, where first one was over 30 years old and because of NGO intervention dwellers received better infrastructure and livelihood services, on the other hand second slum was just 1 years old and received no services from Government or NGO. These differences help me to compare based on health issue. Another reason of selecting these two slums was that, I had an experience to work in those two slums before; as an interpreter of a PhD researcher (which was a par time professional job). So I was well-known in both of slums which helped me to get accesses in field and to select my key respondents. A detail about two slums has been described in chapter four in context of the research.
3.2 Unit of Analysis
In every research a unit of analysis is necessary to fixed for systematic data collection and further analysis. In this research household is taken as the unit of analysis for data collection. Though as a concept household is not constant but dynamic and changing in terms of staying and sharing all component by their members (Ahmed:2000), but in present research to identify the problem of chronic illness and environment, I need the information about people only who are living in slums regularly. This is because, present members of households are important to describe the relation between chronic illness and environmental indicators in slums. That is why, by putting aside the debate about the concept of household, I have selected specific type of household as unit of analysis. Information about all members was taken from a single person from each household.
3.3 Selection of Sample
Sample selections procedure for fieldwork took place into two steps. First, for quantitative data collection, from both slums, 80 households were taken for questionnaire survey by the help of key respondents and own past experience. Considering the ratio of population, stability and size of slums, 50 households were selected from bigger one (Tekerbari) and 30 households were selected from smaller one (Raishertek). All households were selected randomly where Respondents are chosen not merely by certain profession and age, but also different types of professionals and age sets. Secondly, after completing the survey on 80 households, 20 of them have been selected for qualitative procedure. These 20 households were selected by considering those households who are suffering from chronic illness caused by environmental problems.
3.4 Data collection Methods
For this research both quantitative and qualitative data collection methods were used because of two steps of sample selection. Though qualitative methods were in the centre of this research but quantitative data collection tools were used for survey. Here I described all methods and tools in two parts.
3.4.1 Quantitative Research Tools
a) Questionnaire
Survey was conducted with semi-structured questionnaire among 80 households; whereas, 65 are female and 15 are male from both slums. The questionnaire contained 4 pages including 18 questions (see appendix). Most of the questions were close ended and few of it were open ended; specifically question about recommendation of resolving problems. One respondent has been chosen from each 80 households. Each questionnaire took approximately 30 minutes to be finished.
3.4.2 Qualitative Research tools
a) Key Informant
Key Informants played central and important role in total fieldwork procedures. In every steps of fieldwork, these key respondents helped the research by sharing their knowledge, experience and social connections. As an outsider I was unknown to slum-dwellers but from my past experience I was able to introduce myself with key respondents. At first as a student I had explained my objectives of this research to my key Key informnats. Almas from Raishertek and Ruma from Tekerbari acted as my key informants. Almas with his family is living in Raishertek since it was built and he has easy access to all residents of that slum. Ruma, a woman living in tekerbai slum from her childhood was chosen as key informant as she is well reputed in that area. She is acting cashier of community fund from DSK project and also a paramedical informer of BRAC health project. That’s why she knows every household in slum and has a well acceptance. These key informants helped to select households for quantitative survey, communicating with selected households, socio-economic backgrounds of slums, information about water, sanitation, educational and health facilities and other environmental infrastructures. Key informants were also interviewed.
b) In-depth Interview
In this research, in-depth interviews have been taken from both slums from different age and occupations. From survey of 80 households, 20 were selected for in-depth interview. From Raishertek 7 households and from Tekerbari 13 households were chosen for this section and here I gave the importance on research objectives as the relation with chronic illness for environment problems. They were agreed to give interview in their leisure time and some time I continued the conversation in their workplaces also while they were working. I was offered to have tea and I also offered them during interviewing. A checklist is used for in-depth interview where, all themes and queries of the research were included. Besides these themes, all other related issues were also discussed during the conversations. Approximately an hour and fifteen minutes have been passed for each in-depth interview.
There was no specific gender based target about respondents and I selected respondent for in-depth interview according to their availability in houses during my field visit. Female respondents are found more than male because generally male members stay outside in day time. In case, if there were no adult member found in any selected household during my visit, then I tried to find out adult male of female members at nearby working places. Some males and females are working near the slums or inside the slums. To identify the relation between particular professions with illness, sometime I had to wait for female garments workers of some selected households in their holydays. In some cases when I didn’t found any adult members, neither in houses or in nearby working place during my field visit, I had to exclude that household from my qualitative list and replaced it with another one.
c) Focus Group Discussion (FGD)
Four FGDs were conducted in two slums; one with females and another with males in each slum. Both female FGDs took place in two key respondent’s house. Male FGD of Raishertek took place in front of tea stall and inside a restaurant at Tekerbari. Around 6-9 participants were present in each FGD. A checklist is used for FGDs and around two hours have been passed for each.
d) Case Study
Another useful qualitative research tool for the research is case study. A household may be a case or a person; case study method can provide more information as When the qualitative in-depth interviews were being taken, if I found any severe chronic illness story or illness indicating environmental problem, then I select that households as case study. By this way I have taken four case studies. In this research, household is taken as a case from the respondent of that household. Through the cases, respondents’ perceptions of chronic illness, causes of chronic illness as environment, impact on their household economy and their strategies to cope with illness are reflected.
e) Participatory Observation
Participatory observation is used as a continuous tool in whole fieldwork from field selection day to the end of field visit. In every steps and task during the fieldwork observation was proceeding besides other methods. Some respondents among females are working in hair sorting room situated inside the Tekerbari slum; I got an access in their workplace to have conversation with them as the owner of that business, Mustak was also one of the respondent; in the meanwhile their working environment was also observed. Male respondents who are working near to the slums, their working environment is also observed, for an example, almas, a day laborer who is working in fishing project of the Jhil (lake) interviewed in his working time. Besides in-depth interview, respondent’s living conditions and other surrounding environments like housing patterns, water, sanitation is observed.
In addition, some times were passed by gossips with slum dwellers and that gossips helped to build rapport with my respondents. I had to stay in slums until night to keep some request of my respondents making gossip or to listen in their different stories. I also shared some little information about illness and medication with them that helped to make conversations easier. Sometimes I waited for long time for information when housewives were working such as collecting water in water point. Therefore, direct observations of daily activities of the respondents constituted which is one of the major strategies