Global Health Memo, Term Paper Example

Precis

India, as an emerging economic power with limited social infrastructure, faces a number of challenging public health issues.  There are two main causes underpinning these complex issues.  First, as the Indian economy has experienced explosive growth over the past twenty years, migrants from rural areas have increasingly gone to cities in order to pursue greater economic opportunity.  This mass migration has not only put stress on already overcrowded urban areas, but also caused further problems due to poor housing, a lack of sanitation (including healthy food and clean water), and the tendency to live in slums (close quarters). Second, due to the government’s prioritization of other issues or uncertainty over the correct policy prescriptions, public health infrastructure, including resident access to quality primary and preventive care services, is thoroughly lacking.  Thus, not only do many individuals live in sub-optimal environments exposed to numerous health risks, but even if they get sick, they do not necessarily have access to resources to get better.

While India faces a number of urgent public health problems, the government could make the largest impact by helping to construct healthy housing and sanitation for the individuals living in the Gav Devi slum.  This is because although an investment in public health infrastructure might help to deal with the downstream effects of the illness emanating from poor living conditions, it would not be definitive in improving these residents’ quality of life.  That is, while it would help individuals to deal with their current health problems, it would do little to ameliorate one of the fundamental causes of their illness problems: a poor and unhealthy physical infrastructure.  Through investment in quality housing, sanitation infrastructure the residents of Gav Devi are likely to experience a better quality of life and lower burden of disease.

Descriptive/ Analytical Component

The country of India in general, and the slum of Gav Devi in particular, suffer from a constellation of public health problems. Indeed, these problems are not isolated, but rather are intricately connected to the environment where individuals live and work. Although there will be a full analysis presented regarding the data and investigation of the problems specific to Gav Devi, a word must first be said regarding the public health priorities and funding in India, which although not explicitly addressed in the fact pattern, certainly contributes to the lack of public health infrastructure that plagues Gav Devi and other such cities.

India is an up and coming economic power; its influence on the global economy immortalized in its inclusion in the popular “BRICS” emerging market acronym of Goldman Sachs.  Despite its increased economic resources, however, the Indian government has not substantially increased fiscal resources dedicated to dealing with public health problems.  Indeed, as the fact pattern provided aptly points out: The Indian government has placed its political and fiscal priorities on military and (regional) strategic issues  rather than building domestic social infrastructure ranging from effective education to affordable health care.  Although other countries typically spend in excess of 5% their GDP on the public health budget, India’s 4.4% investment is low, even for an emerging country with limited resources.  This has led to a number of urgent public health problems, particularly as migrants hoping to cash in on dreams of economic growth have migrated to slums in major cities such as Mumbai that lack proper water, sanitation, housing and road construction.  Indeed, Gav Devi, a slum consisting of 3,500 individuals in the city of Mumbai, is one symbolic example of how (under) investment in public health infrastructure can have a profoundly negative impact on the population.

Before looking at the specific health problems found in Gav Devi, a quick description of the demographic characteristics is warranted.  First, a quick description of how the data was collected and potential limitations in basing robust analytical conclusions on this data set. The demographic characteristics were based on a random survey that used self-report measures for 100 families.  Although there is no further information regarding the “random” nature of the survey that might help one to ascertain its generazability to the population of Gav Devi , the use of self-reported measures cannot be verified, and thus might contain some bias.

From the demographic survey, the average size of the household was roughly 5.14 members; the majority of individuals in the household were young, with few above the age of 55.

The slum suffers from a number of social problems.  First, the slum has a high level of illiteracy and low level of education: roughly 33% of the slum cannot read, and only one-half of the population has studied at the primary school level.  In addition, a low level of the population is employed (32.6%), with a large part of that population 12.6% with irregular work that helps contribute to the overall low socio economic status of the village. This low economic status ripples through the village in the poor level of health that is related to poor housing the burden of disease in the village.

A majority of the households had a monthly income of roughly 19 US dollars (1000 rupees); 20% of the total sampled households had a monthly income of roughly 10 US dollars (500 rupees). Due to the low income level in the village, a number of problems manifest in the area of health and social development.  That is, the quality of housing in the area is quite low; only two households have water tap inside the house, while others must use public water that can be dirty and expose individuals to disease.  Finally, there is a lack of roads in and out of the village meaning that the same path where there is unclean water and sewage is also the same road where adults and children walk.

The public health problems found in the area are intricately connected to the surrounding environment.  This is especially evident in understanding the main sources of morbidity in the slum: skin problems, stomach issues, and fever.  All three of these conditions, to some extent, are a product of unclear water, air, and exposure to sanitation that should not likely be in open air areas.  Health care and environment likely both play key roles in the burden of death in the slum where infant mortality is high, and the survey might not catch the increased incidence of diseases such as TB and HIV/ AIDS.

Indeed, overall the slum suffers from highly interconnected factors that contribute to its overall poor health status.  Starting with the fact that the slum attracts rural migrant workers, a majority of them without fixed work, and without a high income, they naturally face barriers to achieving quality health care.  At the same time, the slum’s (toxic) surrounding environment adds  to this by exposing individuals to a number of disease inducing factors that tie back into access to health care services.  Thus, the picture presented in the data and description is one of a community that faces numerous public health issues, but also one in which they are mostly interconnected together.  Any attempt to make a difference in this community must focus on dealing with the interconnected nature of the challenges, rather than singing out one particular factor and attempting to dealt with it.  

Strategic Note

As the previous analytical section demonstrates, the slum of Gav Devil faces a number of urgent public health issues.  These issues range from cradle to grave: a high infant mortality rate, a substantial morbidity disease burden, and the emergence of dangerous chronic diseases such as HIV/AIDS and TB.  When looking at how to best tackle these issues, however, there are two distinct strategic directions: upstream and downstream.

The upstream strategy attempts to deal with why people get sick in the first place.  Referring back to the analytical section, the main source of disease morbidity dealt with fever, skin problems, and stomach ailments: all of these conditions are intricately connected to the environment.  Even regarding some conditions related to the high infant mortality rate might be related to environmental sources.  By attempting to deal with issues in the surrounding environment that include providing quality housing, installing proper sanitation system, and building proper roads and sidewalks, residents would have significantly reduced exposure to disease inducing compounds.

The downstream strategy attempts to deal with problems once they have emerged with proper health care services. This is also an urgent problem in the slum: Although there is one private clinic and the slum, and two private slums outside, access to quality health care is obviously an issue that any strategic review should consider.  But that consideration should also weigh the costs and benefits of favoring an upstream strategic solution versus a downstream strategic solution.  Since the instructions explicitly states that one intervention must be selected, a hybrid strategy of upstream and downstream interventions, perhaps the optimal blend, cannot be selected.

Thus, I believe the most effective strategy would be to help ameliorate the upstream sources of morbidity and mortality rather than investment in health care services.  There are three reasons for this recommendation.

First, while investment in the health services might allow for marginally better care, it will not prevent one of the main sources of morbidity in the slum.  That is, there is a tradeoff in that decision that by potentially eliminating some sources of mortality (such as infant mortality), one would  also be exposing those individuals to same environmental factors that inevitably lead to heavy morbidity burdens and the spread of fatal infectious diseases (e.g. TB).  A strategy that focuses on improving the environment, on the other hand, would likely have a more direct impact on reducing skin infections, fevers, and stomach disease- this would have a direct pay off in ensuring better health for individuals in the community without necessarily be dependent on health services.

Second, the downstream strategy is harder to implement, particularly without support at the highest levels of government to change how health services are allocated.  While a better environment may pay direct dividends in improving the community’s overall health, a new clinic would also need to be accompanied by larger changes in how access to the clinics is affected.  Indeed, one of the main problems emerging from the given fact pattern is the area’s low socioeconomic status and (below) average income, even compared to India’s low per-capita GDP.  If additional health infrastructure was built in the slum, this would need to be accompanied with a larger commitment that services would not be paid out-of-pocket- a key barrier to access quality health care in the current setting.

Conclusion

This paper has looked at the current public health problems India faces in general, particularly focusing on the public health issues of a village Gav Devi.  Gav Devi, although a small slum located in the bustling metropolis of Mumbai, is symbolic of many of the problems currently faced throughout India: The slum is largely composed of migrants from rural areas looking for economic opportunity living in sub-standard surroundings. As a result of inadequate local physical infrastructure and the inability of the central and local government to invest, a number of infectious and chronic diseases are common in the slum, with little recourse to quality medical care in the case of illness.

In order to ameliorate this situation, I have proposed to increase investment on quality housing, sanitation, and other physical infrastructure that will play a key role in preventing dangerous infectious diseases such as TB. There is, potentially, a compelling case for advocating increased investment in health care facilities, particularly those available for Gav Devi residents to help them improve overall health. As a first-order approximation, however, building more clinics while leaving individuals living in dirty and dangerous surroundings would only likely lead to greater health utilization without the ability to fundamentally solve one of the causes at the core of the area’s heavy disease burden.  The building of new housing and sanitation infrastructure would not only prevent a number of communicable diseases, but even if an outbreak were to emerge, the effect would not be amplified through dirty water and close surroundings.  Indeed, the investment in infrastructure is investment that will not only pay off for this generation, but for generations to come.