Bengaluru Oct 4, 2019, (Research Matters):
In the heart of the bustling ‘silicon city’ lies one of Bengaluru’s biggest slums, called Devarajeevanahalli. The streets here are lined with temporary shacks facing open sewers and are vulnerable to the slightest fury of the rains. Most houses have one room that serves as the area to sleep, cook and bathe. According to the official numbers, about 2,500 should call this unsightly neighbourhood their home; about 50,000 do so in reality.
Overcrowded, poor and hotbeds of diseases—most of India’s slum fit this description. Despite this, people who live here have little access to clean drinking water, sanitation or healthcare. As a result, many are vulnerable to a spectrum of diseases—infectious and chronic.
“Slums in urban areas are growing at a rate faster than the cities themselves. The vicious cycle of poverty and ill-health is conspicuous here,” says Dr Upendra Bhojani, Director at the Institute of Public Health, Bengaluru. Dr Bhojani has worked for eight years on understanding chronic diseases that plague Bengaluru’s urban poor.
Healthcare facilities are often informal or absent in shanty towns and hence, putting numbers across how many inhabitants in slums suffer from what diseases is a challenge. Unlike others in the city, those living here have no permanent address, and this hinders survey efforts. The rampant alcoholism and crime rates in these areas add to the difficulty in collecting data. Hence, not much is known about the kind of diseases people here have and their prevalence.
In a recent study, researchers from the Bangalore Baptist Hospital, Bengaluru, Zuyd University of Applied Sciences, The Netherlands and the University of Sheffield, UK, have attempted to find what ailments plagued the residents of Devarajeevanahalli. This study is published in the journal BMC Public Health.
“Devarajeevana Halli is one of the biggest urban slums, situated in the eastern part of Bangalore with poor infrastructure, over populated, and slum dwellings with resource poor settings. It was chosen as it is fairly representative of any slum of a big city in India,” says Mr Shailendra Rao Nalige. He is the Co-Founder and CEO of RX Digi Health Platform Pvt Ltd, Bengaluru, and was involved in this study.
The study involved door-to-door surveys of about 1200 households and screening of 3700 people. A team of social workers, technology experts, nurses and doctors collected data about the socioeconomic status of the family members and their health parameters. These parameters included body weight, height, body mass index (BMI), haemoglobin, blood pressure and random blood sugar.
THULSI to the rescue
Although some studies have provided insights into the prevalence of chronic diseases like diabetes and hypertension among the urban poor, most of them have relied on self-reporting by the survey participants. Besides, household surveying entails carrying bundles of papers, painstakingly writing down every little detail and collating them all to derive meaningful insights. For the kind of information collected in the current study, conventional survey techniques would be not only tedious but also error-prone. Besides, it is a Herculean task to follow-up or trace paper-based medical records.
The researchers’ answer to this challenge was the THULSI toolkit—a versatile, handheld toolkit designed to collect health-related data. THULSI, short for Toolkit for Healthy Urban Life in Slums Initiative, is a mobile and modular toolkit weighing about 3.5 kilograms. It was developed as a collaborative effort by the researchers and two local companies—Icarus Nova and Mr Nalige’s RX Digi Health Platform Pvt Ltd. It contains testing devices like a glucometer, BP monitor, weighing scale, tape and other necessary components and an Android tablet with a purpose-built application (app). The app is designed to capture the data collected during the survey. “M/s Rx Digi Health Platform Pvt. Ltd., (DHP) initiated the digital method of capture of demographics and vitals using an Android App to enable systematic plans for data collection & clinical follow up. Its purpose was to increase the throughput, using trained health worker to get digital data for data analysis using DHP’s cloud platform,” explains Mr. Nalige.
THULSI can also connect to a thermal printer through Bluetooth to print out the test results instantaneously. When necessary, the survey participants were told of the diagnosis and the required medical interventions. The toolkit was found to be much more efficient than paper-based surveys.
“Over a period of 10 days, on an average, each team could cover 24 households per day, and screen about 74 subjects,” says Mr Nalige.
Slums in a pickle, results show
The study found interesting insights about the living conditions, socioeconomic status, health and morbidity of the individuals in the slums of Devarajeevanahalli. Most houses here had a single room with different portions of it being used for cooking, sleeping and washing. A third of the residents did not have access to the public food distribution system. About 70% had the Below Poverty Line (BPL) card, which provided access to subsidised food and medicines. Only a handful had health insurance.
The health of the residents was concerning. One in three residents reported some illness. About half of the deaths in this neighbourhood were of adults in the age group of 20-59 years with a death rate of about ten per thousand. Nearly 30% of these deaths were attributed to heart attacks, the most common cause, followed by road accidents, tuberculosis, alcohol-related deaths and other infections.
Data collected from the diagnostic kit showed that one in three individuals had hypertension (35.5%), and about one in five had diabetes (16.6%). Interestingly, half of those with hypertension and one in three people with diabetes are unaware of their ailments before the screening. Among those newly detected as being hypertensive, 59.7% were female, and 53.1% were younger than 50 years. For the newly-detected diabetics, these numbers were 68.1% and 52.8% respectively.
“These numbers, in general, are in agreement with our studies on the prevalence of chronic diseases in other slums of Bengaluru,” says Dr Bhojani, who was not a part of this study.
“We have seen an increase in the number of people reporting these conditions over the years of our research. Even after almost a decade, it is interesting that this trend has not changed,” he remarks.
“Unidentified diabetes and hypertension in this population can be one of the reasons for heart attacks and premature deaths,” say the authors of the current study.
Besides, migration from villages to slums has altered the physical activity and diet patterns of these inhabitants and provided easy access to smoking and alcohol, making them susceptible to these lifestyle-related diseases.
The study also found that nearly 70% of the residents had anaemia—a prevalent condition in South Asia. Among women with severe anaemia, 55% belonged to the age group below 30 years. The researchers hypothesise that poor housing, overcrowding, pollution, increased exposure to infectious diseases and reproductive tract infections, along with limited access to healthcare, contribute to the high prevalence of anaemia.
Interestingly, almost half of the children under the age of five years were stunted here, while 40% of the adults were found to be obese. While obesity leads to increased mortality, severe malnutrition could impair the cognitive, social, emotional and physical development of the children, trapping them in poverty forever.
Figure 1: Prevalence of morbidity in the screened population of the study [Data Source]
The findings of the study show that Household health screening and opportunities for treatment have the potential to reduce the burden of serious health consequences in slum populations.
Tiding over alarming trends
Once considered the diseases of the affluent, cases of hypertension and diabetes are now rising among the poor too. Most of our healthcare systems catering to the poor are equipped to address acute illnesses, like tuberculosis and malaria, and not chronic diseases.
"Most of these follow the ‘treat and forget' approach, without stringent follow-ups. However, the ability to address chronic illnesses, that need medications and follow-ups, will be a litmus test to our healthcare systems," says Dr Bhojani.
Many programs launched to address healthcare concerns in India have focused on the poor in rural areas. However, as the rural poor migrate and become the urban poor, these programs also need to change to cater to this growing population. One such example is the National Urban Health Mission, a sub-mission under the National Health Mission, focussing on the urban poor. But, as the findings of the current study indicate, there needs to be more concrete efforts in this direction.
The Bangalore Baptist Hospital, for one, has started some initiatives to tackle these healthcare challenges. Community meetings, nutritional counselling, nurse home visits and mobile clinics have been operational to monitor diseases in Devarajeevanahalli. A project called 'Little Einstein' has been initiated to address malnutrition.
Mr Nalige suggests some actionables for the government to help address the healthcare challenges of urban slums.
“The government needs to finance institutions to catch patients with non-communicable diseases early on and plan timely. It has to promote digitally-aware healthcare workers to reach the poor areas to serve better,” recommends Mr Nalige. “Insurance schemes for regular screening of chronic non-communicable diseases, timely follow ups and appropriate interventions can improve the productive life years of the slum dwellers,” he concludes.