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Urban Suffering Studies Center



Chapati on the floor and women beyond violence

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Marzia Ravazzini



To understand the case study presented below, better to know it is the third phase of the research " Demand and supply: access to health - paths of care for very vulnerable people living in the big cities", whose the two previous phases has been published on Souqonline Annual Book.
To go foward, the research identified Mumbai - the megacity - Urbs prima in India1 - in India, as the research field from a relevant point of view: Dharavi - the slum - or better definied a neighbourhood2 of about 2 millions of inhabitants.
The slum is a real paradigm of the urban suffering and of the complexity of living in a big metropolis, starting from the vulnerable residents.

Context Trace

Mumbai, Dharavi: Rajiv Gandhi Nagar

We are in India, in the city of Mumbai, and precisely the research field is the biggest slum of Asia, Dharavi4, in the beat called Rajiv Gandhi Nagar, the western part closed to the Deonar Deposit and the border canal.
Inside the slum, the researcher attended the Urban Health Center (UHC) of the Sion Chota public hospital, run by Lokmanya Tilak Mumbai Municipal Corporation (LTMMC).

The Twelfth five Year Plan - Social Sector
Planning Commission of Government of India

As a spontaneus evolution of the vulnerability, complexity and urban suffering concepts of the reserch, the third phase in India has not any kind of comparative aims on the two health systems (Italy - India).
Beside this observation, however, it is important to put in context some aspects of the indian health system, taking into consideration the governamental plan, called Twelfth Five Year Plan (2012-2017) of the social sector, edited in the 20135.

At the time of collecting data, India's health care system consists of a mix of public and private sector providers of health services. Networks of health care facilities at the primary, secondary and tertiary level, run mainly by State Governments, provide free or very low cost medical services. There is also an extensive private health care sector, covering the entire spectrum from individual doctors and their clinics, to general hospi- tals and super speciality hospitals.
The system suffers from the following weaknesses:
1. Availability of health care services from the pub- lic and private sectors taken together is quantita- tively inadequate. This is starkly evident from the data on doctors or nurses per lakh of the popula- tion. At the start of the Eleventh Plan, the num- ber of doctors per lakh of population was only 45, whereas, the desirable number is 85 per lakh population. Similarly, the number of Nurses and Auxiliary Nurse and Midwifes (ANMs) avail- able was only 75 per lakh population whereas the desirable number is 255. The overall shortage is exacerbated by a wide geographical variation in availability across the country. Rural areas are especially poorly served.
2. Quality of healthcare services varies consider- ably in both the public and private sector. Many practitioners in the private sector are actually not qualified doctors. Regulatory standards for public and private hospitals are not adequately defined and, in any case, are ineffectively enforced.
3. Affordability of health care is a serious problem for the vast majority of the population, especially in tertiary care. The lack of extensive and ade- quately funded public health services pushes large numbers of people to incur heavy out of pocket expenditures on services purchased from the pri- vate sector. Out of pocket expenditures arise even in public sector hospitals, since lack of medi- cines means that patients have to buy them. This results in a very high financial burden on families in case of severe illness. A large fraction of the out of pocket expenditure arises from outpatient care and purchase of medicines, which are mostly not covered even by the existing insurance schemes. In any case, the percentage of population covered by health insurance is small.
4. The problems outlined above are likely to worsen in future. Health care costs are expected to rise because, with rising life expectancy, a larger pro- portion of our population will become vulner- able to chronic Non Communicable Diseases (NCDs), which typically require expensive treatment. The public awareness of treatment possibilities is also increasing and which, in turn, increases the demand for medical care. In the years ahead, India will have to cope with health problems reflecting the dual burden of disease, that is, dealing with the rising cost of managing NCDs and injuries while still battling commu- nicable diseases that still remain a major public
5. Health challenge, both in terms of mortality and disability. The total expenditure on health care in India, taking both public, private and household out- of-pocket (OOP) expenditure was about 4.1 per cent of GDP in 2008-09 (National Health Accounts [NHA] 2009), which is broadly com- parable to other developing countries, at similar levels of per capita income. However, the public expenditure on health was only about 27 per cent of the total in 2008-09 (NHA, 2009), which is very low by any standard. Public expenditure on Core Health (both plan and non-plan and taking the Centre and States together) was about 0.93 per cent of GDP in 2007-08. It has increased to about 1.04 per cent during 2011-12. It needs to increase much more over the next decade.
The enormity of the challenge in health was realised when the Eleventh Plan was formulated and an effort was made to increase Central Plan expendi- tures on health. The increase in Central expenditures has not been fully matched by a comparable increase in State Government expenditures. The Twelfth Plan proposes to take corrective action by incentivising States.

Among different partners present into the hospital tertiary services, there is the NGO SNEHA.

A secular, Mumbai - based non - profit organisation, SNEHA believes that investing in women's health is essential to building viable urban communities. SNEHA targets four large public health areas - Maternal and Newborn Health, Child Health and Nutrition, Sexual and Reproductive Health and Prevention of Violence against Women and Children.
Its approach is two pronged: It recognises that in order to improve urban health standards, its initiatives must target both care seekers and care providers. It works at the community level to empower women and slum communities to be catalysts of change in their own right and collaborate with existing public health systems and health care providers to create sustainable improvements in urban health.

At the moment of collecting and in concert with socio-sanitary workers, the researcher explored the slum together with already known families or new ones; a note necessary to clarify some data: the homevisits have been often conducted in a collective way since the researcher and the traslator were always introduced by SNEHA' s community workers, inside the houses or on the narrow streets.

During the sunlight, the slum appears a female world, populated and lived by women colours, with scent laundry, household noises and children screams. Men are outside, looking for a job or any activities, so that the situation is just effect to conduct interviews and talk slowly, without pressures.


The Case Study

In politics we will be recognizing the principle of one man one vote and one vote one value. In our social and economic life, we shall, by reason of our social and economic structure, continue to deny the principle of one man one value. How long shall we continue to live this life of contradictions?
B. K. AMBEDKAR, 1949

In 2008 Mumbai reached the standard of living of Los Angeles, if we consider in brief, that the richest man in the world built for himself the world's richest house in this city. Since then up to present times, Mumbai has increasingly become a global city just like other megacities. Today, for example, the rich can order a trip by limousine from apartments by Philippe Starck6, to Versace boutiques and then go to a restaurant facing the sea to eat excellent sushi, crossing a beautiful, light suspension bridge over the ocean.
Today, as soon as you arrive in Mumbai, you can travel along an elevated highway, surrounded by
green palm groves, linking the city centre to the new international airport named by Minister Praful Patel in his speech at the inauguration of 2014, "the most beautiful building of the city built since gaining independence".
But if you just looks down from this elevated highway, any traveller can see the Annawadi slums, which literally means "empty bottles thrown away". Despite indian economic growth, more than 40% of the residents of Mumbai live in settlements called slums, such as Annawadi and Dharavi, where vulnerable individuals live, united and defined as slum dwellers7 and who, as in other indian cities, are rarely considered poor by the Indian Government. According to statistics, in fact, they are among the hundreds of millions of Indians who have been lifted from poverty since the beginning of the economic liberalization (since 1981)8.
The american writer Katherine Boo, Pulitzer Prize (2000)9, spent more than three years documenting the life of a small corner of a vast continent and in her work, forthright and controversial, she continually asks one to put themselves in the words and shoes of the poor.
The pressure that she tells of, is the same as that heard of in Dharavi and in other cities around the world, that which is suffered by those who have to struggle every day: where can I sort out my identity document? How can I be sure that my hovel is not demolished by a bulldozer of the government or the authorities of any corporation interested in that piece of land? How can I ensure a valid education and offer good formation opportunities for my children? Where can I find a steady job? How do I switch from my basic cell phone to a smartphone? How can I perhaps - dreaming - afford a two-wheeler? But in the meantime, how can I avoid an infection from the water I drink, that would lead to a public hospital where perhaps they have neither medecines nor food? And, once again, how can I avoid running across authorities or policemen who take advantage of me because they know I have little chance of liberation?
Conflicting visions and questions like these are the perennial material documented in descriptions, called for by the strong contrasts of Mumbai, where the richness of the Malls is shamelessly accompanied by the poverty of a group of female migrants weaving straw into baskets by the side of the road.
And it is not enough to think that this is the life of the residents of the slum and that it will remain so forever. It would be like immobilizing their existence and considering them always "others", as described in the film Slumdog Millionaire10.
The feeling of a permanent, unchangeable situation, - due to its complexity or even because of a cultural justification (for some, through the caste system) - continually happens throughout the research work, causing moments of discouragement and also emotional and rational fatigue.
In reality the situation that appears to be completely established and far off from everything is very dependent and influenced by the dynamics of the international global market.
The descriptions of those who live in these places are typical of the "culture of the other" 11 far from us; but to believe that these same places consist of only poverty, suffering and deprivation, is an oversimplified way of reducing their lives to lives that are different from ours. It's a simplifiction that de-humanizes, and that does not do justice to the dignity of people and the complexity of the structure of these communities.
The economic growth of India has been defined precocious by economists, or rather, rapid in certain sectors, but not in those that generate work. Hardly anyone within Dharavi has a permanent job, or a private insurance or pensions which permanent employment grants. A small error, or a bit of bad luck, or even the envy of a neighbour in a nearby shack can destroy the hard work of a lifetime.
The instability of the situation of being vulnerable is well described by a young boy I met while sipping tea with milk: "a decent life is the train that hasn't hit you, the boss of the slum you haven't offended, and malaria that you haven't contracted".
In recent years, the precarious existence of slum dwellers has become even more fragile in relation to the volatility of global markets.
Really what happens in finance in New York or London, oceanic distances apart, can quickly cancel the dignity of a 12 year old boy who collects garbage near the airport and who - as suggested in a play - says: "everyone keeps on saying Wall Street, everyone keeps on saying the collapse of Wall Street... and I, from here, can tell you what really changes with these words: a chilo of empty bottles that just a few weeks ago was worth 25 rupees, today is worth 10"12.
What is particularly fascinating when meeting these people of the slums, is the naiveté, full of hope, mixed with resignation with which the people live in instability and within a ruthless system.
To sell samosas on the pavement near a petrol pump, collect rubbish in the street every day, to stand all day long waiting for someone to call them for work, while they cough and spread tuberculosis as lorries go by: all this for them means trying again and continually, because maybe something could happen and eventually work out, with the knowledge of a mother, who wisely says:

"yes, it's true, even if the world is not on our side".

With these emotions in my body and brain I face a day in Shahinsha's home.
I have already met her eldest son, and I know where they live, I know the dark wooden door with the padlock on the outside which is the access to her world. The people here don't close the door when they're inside, the lock remains outside for when you leave home and you're away.
It's the second street on your right, at the beginning of a blind alley that together with another small road with a sharp bend, overlooks the small Rajiv Gandhi Nagar Square. I recognize it because it is painted a bright pink, and has tiles on the floor.
It's morning, Shahinsha is waiting for me with dark round eyes and a wide mouth ready to break into a smile; she's sitting on the floor, together with her mother Saida.
Her children, two boys of 14 and 11 years old, attend the MPES High School, an english government school, and they respectively dream of becoming a computer engineer and airplane pilot.

"It's just as well that the boys are at school: they leave home at 7.00 to begin lessons at 7.30, then they come back home at 13.30 ... that way - she says - we have time for a chat between women".

Her voice is deep, with a firm, high tone. She insisted that I chose her for spending this long day together, because she confessed that she wanted to know about other ways of thinking.
Hospitality in India is sacred, and in taking pains to offer me something, she cooks onions, brings me a plate of green chilly and lime, chopped tomatoes and watermelon with parsley and looks for a cold drink in the fridge.
Shahinsha's house - here it is called chawl13 and is one of the best I have visited in recent months: consists of a single room divided into three spaces: one is the main room, with wardrobe, television and even a refrigerator of a bright blue reminiscent of the seventies, two shelves full of all sorts of things, and a small mezzanine - the second space measuring roughly 3mt by 2 - that can be seen and where one can see the mats and blankets for the night; the third space, separated by a curtain pushed to one side, is the kitchen with cooker and all the utensils piled onto the aluminium shelves; in this same space, about 1mt by 3.5mt, in a corner is the shower space/place to wash in and wash (it has, in fact, a hole as a drain from which the water can go out onto the road).
The smell of onion expands throughout the house and I - as always - cry a bit because of the effect of the vegetable on my eyes.
Saida slowly takes a handkerchief and hands it to me, I don't understand english, but the tears do.
In a slow marathi she tells me how she has been a widow for five years, her husband died from an illness of the kidneys and he was diabetic; she had four children, but only three are left: Shahinsha, another daughter and son with whom she lived for two years in the slum at Naik Nagar. She preferred it there, there was more space and it wasn't like here, without a water supply and with the big problem of public toilets14.
The same comment was made by the journalist Suketu Mehta, explaining that in Mumbai women have to defecate between two and five o'clock in the morning, out in the open fields, as this is the only time when they can find some privacy, because public toilets rarely represent a solution as they are almost always out of order.
But to get back to the slums of Naik Nagar Grandma Saida says they were demolished and so, as the story goes, the son returned to his wife's region, in the country, and she decided to rent a shack here, close to her daughters.

"I'm alone", she says moving her lips tremulously "and without a pension";

occasionally she struggles to do some housework for others, through word of mouth, and manages to cover the rent of 1500 rupees15.
While she is speaking her granddaughter, the daughter of Shahinsha's sister, comes in: she has long black plaits on each side of her head, she is beautiful with luminous eyes; the grandmother offers the granddaughter soybeans served with tomatoes, onions and chilly, and the little girl tastes it, but the grandmother doesn't, the food in this house is too spicy for her.
The fan is switched off but a breath of fresh air comes in from the front door. Once she has finished eating the granddaughter goes back home to her mother. It's a fresh day, but it will soon heat up and then we will have to switch it on. This dampness - says Shahinsha while she dries her face in front of the stove - is nothing compared to the rainy season.

" Then everything is sticky, and we can't even walk,"

interrupts the Grandmother, who wants to tell her own story. When she speaks, the daughter stays silent and continues to work in the kitchen: I suggest that Shahinsha sits with us, but she says she wants to cook me a tasty lunch.
The grandmother asks about my family and my house in Mumbai; as soon as she hears the name of the area of Bandra, where I live with my family for these months, she clings to my arm and says with emotion:

"I used to live there also. I come from a rural village, in the country, then after we married we moved to Mumbai, and my husband started his own business, he had a shoe shop".

There are many young workers who move in search of opportunities in Mumbai, and this is a part of the history of the intense urbanization that over the years has characterized the city. The 20 million of Great Mumbai are well-known, but the characteristic over the centuries was precisely the internal migration of the poor, rural population who came to the city in search of work; it can certainly be said that this happens even today, every day, and it is for this reason that it has been described as "a fast moving city"16.
The shop went well, continues Saida, and we were fine. I had four children, but one later died young, from a severe form of tuberculosis, and so I was left with three. Life in the city was better,
the grandmother confesses:

"...and I would also like to tell you that I was the one who insisted on coming to live here. In the village we didn't have our own house, I lived with my husband's family, and in one word, I had to do everything they told me. I was young and didn't know how to - and I couldn't - say no. I've seen bad situations and I've found myself in them too, because you can't change certain things. I worked hard and for everyone, and
I also had to be kind and smile. And in the dark black evening, when I heard my
husband's father beat his wife, I couldn't sleep. Then in the morning, in silence, I
had to play dumb, and put up with my mother-in-law's anger towards me".

The city, therefore, was also an escape, toward a different idea of life and family. Saida speaks in a low voice and says that she just didn't want to go on living this way, and her husband understood her:
"we were aiming at something different for us and our children," she comments and then: "everything reminded me of my little one that had left us and I didn't want to stay there anymore".

In Bandra, however, we now go to do the cleaning in the houses of people in high places:

" with a rickshaw I would only take half an hour, while the bus takes much longer,
sometimes up to an hour, but I can't afford anything else. We have no means of transport and this city is always full of traffic".

Traffic and pollution are another feature of Mumbai, and of the health and life style that it offers its residents. Living in Mumbai is an experience that activates all the senses, and it is very tiring: the quantity of people everywhere, the noise on the road, the crush on public transport and trains in particular, the stations so full of people of every kind, the air full of perfums and heavy with pollution, and one's sight, stimulated by the colours and the thousand differences and contradictions. All this, and in particular the pollution, can be felt, on the skin and in the mind, and it adds a hint of stress, which makes it tiring to get through the day and unhealthy for one's own existence17.
I reply to the grandmother, telling her that many times I felt privileged to live in that area of the city, just a few steps from the Ocaean, with the possibility - and often the necessity - to breathe the air, to refresh the mind, and walk along the promenade, the walkway looked after by the inhabitants of the neighbourhood, closed to traffic - even to bicycles - to be able to look up and see the sky and the sea.
Saida knows it well, and says she used to go there walking with her husband, sometimes, when the children were young.
Now she doesn't go there anymore, she has just her memories to keep her company. They had to leave Bandra when the shoe shop went bankrupt; and she has no regrets, she says, her husband managed to deal with the economic losses, debts, and the change of "status" but adds:

" our life was never the same again".

A spoon falls, the silence is broken and Shahinsha brings the mixture for chapati:
" flour, olive oil, salt and a bit of water to combine the ingredients...this is the base and then", she says: when you serve them, chapati accompany all dishes, meat, fish, vegetables ...and should be eaten with your hands".

The grandmother approaches the plastic table cloth spread on the floor: the small balls of dough taken from the fridge have to be stretched out by hand, and we all start working, including the translator.
The movements of grandmothers are always the most simple, no kind of indecision or correction, they know how to get around and the result - at least in the kitchen - is always the best. Saida is fast, and manages not to waste not even an ounce of flour.
Her previous words come to my mind when describing their change of life, from Bandra they ended up in a slum and she began carefully counting the money for shopping. In this daily struggle, today, you have to add the solitude and the discomfort of the water and the bathroom that doesn't exist, and also, the promiscuity of the place, with the violence that is at home there.
I bring up the subject with the grandmother, and she says she is very concerned about her second daughter's girls and Shahinsha 's boys.

Shahinsha finally sits down. She has listened to everything, and in a slightly abrupt way, she says that however it went, their life has been good: she hadn't experienced first hand domestic violence, her father had always been good to his wife and to his daughters. She remembers very clearly when she fell in love with her husband, and that she had been able to announce it at home and be listened to by both her parents.

" We are muslims, and for us it is a priviledge to be able to marry for love: I met my husband at work, I worked on the 5th floor, and he was on the second, but the lift was only one, and so after being engaged for three months, we got married, 14 years ago now".

After the first child, Shahinsha didn't return to her white collar job, keeeping the accounts for a company, but she continued to read and study at home, because her dream was to become a teacher.
Her husband looked after her and all that was needed in the family and preferred her to stay at home to look after the children:

" It was fine, it was enough for us", she says convinced and continues:
" Today we live with about 18.000 - 20.000 rupees (250-270 euro) a month and the expenses are high: the rent of the house is 4000, electricity about 2000 - even if we are dependent and "steal from them" we must pay one of the slums 500 rupies - to have access to water, and we consume about 10.000 rupees a month for food...then the public baths are to be paid for, every time that you go it costs 2 rupees a person".

" It's not easy, indeed it's even harder now" she confesses with a tired face:
" Bhabhi18, my husband hasn't worked for some months, and he has been away from home for two months for treatment, guest of a distant relation at Delhi. They diagnosed cancer of the mouth, and he ought to be operated on, but we don't have the money; first we were told about 26.000 rupees (about 353 euros) for surgery, then we went to the Tata Cancer Hospital and there the sum grew, 500.000 rupees (about 6775 euros) plus chemotherapy and medicines".

Her husband is young, he is 32 years old, says Shahinsha continuing her story, but smoking and alcohol have worsened his situation, and I am worried because he has difficulty eating, his cheek is always swollen and he is in pain.

While talking she gets up, takes a small exercise book from a box and then comes and sits nearby. With a big smile, she shows me the photos of her wedding: she is beautiful, young and with a contented look, dressed in red and gold, completely covered with henna on her hands and arms, her hair gathered under a coronet and necklaces everywhere and of various lengths. They married in Dharavi, and according to the custom here, the party lasts for a week with music and dancing and family and friends who come from all parts of the country. It was the 4th of December 2001.

The floral curtain of the front door moves, and the eldest son arrives home. The grandmother prepares food for him, that he will eat together with the granddaughter and the second brother, who arrived shortly after.
They don't have television, nor the cable to connect to, and so we improvise an english/marathi/ and italian lesson while the mother washes and changes her clothes. She knows Italy because the eldest son loves sports and football, while the second appreciates cricket and basketball. Time never seems to pass, the sunlight does't filter through and so the neon light doesn't allow you to understand the passing of the hours of the day.
Everything seems motionless, the grandmother lies down and sleeps, the grandchild plays with the fuchsia painted chick in the big cardboard box, and the two brothers go out looking for friends: you almost have the feeling of peace and of a protected place, contrary to what is described and read about life in the slums.

Shahinsha comes back from prayers, it is 15.50 and I ask her how she feels being alone, without her husband for so long. She doesn't reply, and starts asking me questions about my family, my work and how women manage in the West.
She has always been independent, but the family and the conditions in which they live limit her. She tells how after a few years, she met SNEHA, and how through them she was able to become a teacher and hold some training courses on sexual education for adolescent boys and girls living in the slum. Unfortunately with the ending of the funds, the programme was stopped and she no longer continued working.

" I miss it" , she says handing me her CV:
" because I enjoyed working. The subject wasn't easy, but it was very important for me. Here violence is daily; you can hear screams but no one can intervene. I have two sons, and I am very worried for them because it really is a place where there is a lot of tension. I would like to always know who my children are with, here as soon as they grow up, men come into contact with drugs and alcohol and they have no respect for women. When it's dark I never let them out".

The subject of violence in Dharavi as in other slums, is not easy; the interweaving of culture, hardship, poverty, ignorance, unequal distribution of resources, AIDS, gangs and structural violence is common to places around the world, as Farmer explains in his text: " social forces at work there have also structured risk for most forms of extreme suffering, from hunger to torture and rape"19.
Stories show that domestic violence manifests itself in many forms of abuse, including physical, emotional, sexual and financial. It can be perpetrated by one's partner or any other member of the family, both original or acquired by marriage; this ruthless mix is often amplified on women, young and segregated, who despite having aspirations of independence in mind, tell stories in the present of subordination, burdening their children's future with the change they desire.

" School, education, training, and the use of new technologies can greatly help even us who live in a corner of the world; I would like, for example, to call my husband, on your mobile phone now, because the person who is providing accomodation for him has whatsapp and so we can talk and share laughter and smiles with the boys. May I?"

Shahinsha's request suprises but impresses me with the immediacy of the opportunity.
The phone call is public...there are 7 of us in the room, Shahinsha has just combed her hair, her clean dress is a splendid bright blue, and her smile at seeing the children laugh with their father is immense.
On the phone they speak with respect and they seek one another, the husband wants to see all his family, and also me. He has a swollen cheek, and admits to suffering a lot, but immediately after he reassures the children saying that he is doing the treatment and it will soon be over.
At the end of the call Shahinsha stands up and hugs me:

" I was so pleased to speak to my husband, I was so pleased to see him"

and she asks me to take a photo together that she can keep.
Shahinsha has a lot of courage; she is one of the women in the slum managing a common fund; some confess of doing so without informing their husbands, while others actually, receive the backing and support, not only economical.
She, together with her group of about 20 women, meet once a week, often alternating the chatwh/shack that houses them, to collect small sums that can be useful for important needs/requirements (they refer that the amount is not fixed, but that on average their goal is to save 100 rupees - about 1,4 euros - per week), such as medical treatment for a member of the family of the women involved, or a service emergency within their area, or even for training investments for any of them, the women face the labour issue and compare notes on their state of independence/ daily suffering20.
The economic issue is closely linked to the real aspirations that the women have. I‘ve met many during the homevisits and often they discussed the need to support each other, trying to go beyond the negative attitude shown by their respective husbands, who often decide univocally on every aspect of life, from food to school, from work to be carried out, the house to live in and with whom to share it, even family planning.
Shahinsha does not seem to be dependent; she seems extremely aware of her past and the history of her mother and worried for the future of her children and confesses to arguing frequently with her husband.
" Culture has rules, for example our religion says that women must wear a veil and she
quotes: "so it is written: if you wear it, God is happy", and you can find beautiful ones costing up to 10.000 rupees, extremely enchanting and valuable."

and as she speaks, she puts one on then takes it off, as if it were a game for an act of shared feminine beauty.

" But rules can be changed according to the needs of the story. Now our story says that he is far away, and he is ill, and maybe he won't survive...and I have to work, to keep the family".

She would like to teach this to her children.
(Mumbai, February the 26th 2015)


A vulnerability that recalls the basic needs.

Mumbai has a long history of migration, in just the same way as internal migration has remained characteristic of those who come to inhabit it. Also the women met during the homevisits of this study and within the department are all internal migrants who, living in Dharavi, hold in their hearts the possibility of returning to their regions one day21.
Their life is extremely hard and is characterized by the vulnerability that we have defined according to the four indicators of the research, also supported by an Indian survey, according to which social and economic inequalities are critical contributors of health inequalities for women and children in urban India22: this vulnerability affects their patterns of care, in a priority way: evidence shows how the choice of taking care of ones body and in general of ones health condition is delayed when compared to other basic needs - that is the access to water, food and a healthier nutrition with fruit and green leafy vegetables, the access to public toilets in order to carry out primary needs with dignity and in safety23, fresh air and the possibility of living in a safe environment, free from tensions and violence, where the husband's attitude is listed in a relevant way.
The inequality of health, declared by the WHO document, have prevented India's progress towards the Millennium Development Goals and, inspite of the achievements maternal and child health has reached poor levels24.
Local services are not immediately known, or experienced.. It is the need - and in the case of our female sample - in particular, pregnancy and maternity, that leads to an induced knowledge.
Consequently, the choice of the place where to have treatment is not a top priority: even in this case, access is described as an episode which is necessarily influenced by the lifestyle of the interviewees: the proximity, as well as the time spent getting to the service, (without any means of transport available, nor the money for using it) waiting for the visit, and finally the opportunity of receiving the necessary medicines, are all issues that affect the choice.
Therefore the understandable effect is the presence of the services within the community of Daravi: it is not ones personal doctor, but these are the favourite places for care, and the presence of a public hospital is very valuable, but not sufficient.
The project of SNEHA, as NGO located inside the slum and present within the hospital, is to work on both fronts: informing, protecting, educating and helping women, and at the same time, develop places of care and concern for the dignity of women within the community, while respecting roles and family and cultural decisions25.

Comprehensive care, for a real health question.

Observing care pathways independent of health care demand, has allowed us to deepen the comprehensive health idea, characterized by the ability of experiencing challenges and skills, for managing and coping with ones life style through time.
The health demand expressed by the women interviewed is a complex question, to be interpreted on different levels at the same time, noting susceptibility compared to the acceptance of structural suffering (Farmer, op.cit., 2003):
- The cultural aspect of the role of women within the family and in the society to which they belong, amplified as described by Arundhtay Roy in his annual opening Lectio UCL - Lancet, in 201426 :

"Today, the caste system continues to affect the country's economy, politics, and media, while discriminatory attacks against Dalits persist, with women and young girls often killed or subjected to extreme forms of violence with impunity because of their caste. This ingrained inequality has led to tacit acceptance of the caste system, which has created, among other challenges, a preventable epidemic of mortality among women and children. Indeed, many of India's health indicators fair poorly in comparison with its neighbouring countries and economic peers. To improve the nation's health, the message of Arundhati Roy's Lancet lecture is that politicians need to address the caste system. They must work towards creating equality, opportunity, and investment in health and education. Roy's message is clear. Caste can no longer be ignored in Indian society".
The question of the castes linked to the question of gender is a very complicated and delicate issue: Is the problem the castes or the gender? The observation makes one think above all of the violence related to the gender aspect, which intersects with the issue of the castes, while remaining prevalent in itself27.
- The individuality of the single person who often is alone with her decisions and in her state, and the community that surrounds her, described as neither safe nor benevolent. We would like to point out here the indications of Stern (2004), that there are three classes of influence for the development of empowerment: first there are individual skills (human resources); second there are the external conditions that emerge from the family context, the community environment (including the castes and religions), society, systems of Government, and all the actors that shape people's lives; finally there are inner limits28.
- The idea of a future in some way modifiable: it is clear from the open manner that the women show in their aspiration for a right to health. As for the doctor-patient relationship, in fact, their responses are aimed at a better understanding of health status, through clearer information and a listening relationship with the doctor. In an even broader sense, the referred signs indicate a pathway towards their personal dignity and independence, through work for themselves and a better future for their children thanks to a good education. It's an idea of the future that strengthens the concept of empowerment outlined in the reference literature and that motivates the enhancement of their resources, transforming them into skills.

Traditionally, in India there are not many people who have given voice to their opinions in relation to the health care system: it is interesting then, to refer here, to the campaign The Right to Healthcare guided by Jan Swashtya Abhyan29 (, which provided the instruments to monitor the community-based approach in the planning and implementation of health services (National Rural Health Mission 2007). The process has developed extremely well in the Maharashtra region, with the participation of about 1000 villages out of 13 health districts, highlighting the possible role of the participation of patients in healthcare:
" When access to basic care is uncertain, the discourse on patient centred care shifts from individual doctor-patient interaction to collective engagement and advocacy by communities to make the health system function and deliver their needs".
The newly proposed national healthcare law intends health as a fundamental right, with a promise to improve access to care: this vision can only be achieved through active involvement and participation of the people, reports Anita Jain, editor of the British Medical Journal30 (feb. 2015).



Methodogical annotation

This work has been conducted with the precious help of the field translator, Savita Chandanshive, social worker and student of TISS31of Mumbai; she has been chosen because of her own specialization in public healht, the knowledge of the three main languages spoken (marathi - hindu - english) and for her expertises linked with two different projects within two urban settlements in Mumbai as reserachers of TISS, under the supervision of prof. Matthew George, TISS. She has received a special training in etnographical research32 on field by the author.




Suketu M., Maximum City, Bombay città degli eccessi, Einaudi, Torino, 2006 e 2008.
2 Echanove M., Slum' is a loaded term. They are homegrown neighbourhoods", The Guardian, Nov 28th, 2014.

3 In The Challenge of slums, rapporto storico de Human Settlements Programme dell'ONU (UN- Habit, London, 2003).
4 as written in Sharma K., Rediscovering Dharavi, Penguin Books, India, 2000: " Dharavi is a village made up of people for more than fifty other villages, it is literally a mini- India. Tha Dharavi mix, if one can call it that, emphasizes a central facet of Mumbai which we tend to forget in a era of identities politics, that this is a city of migrants", p.36.

5 Twelfth Five Year Plan (2012-2017), Social Sectors, Volume III, Planning Commission (Government of India), SAGE Publications India Pvt Ltd, New Delhi 110 044, India 2013,

6 read more on "Book a Philippe Starck-designed apartment in Mumbai ", Vogue in March 17, 2015.
7 Gli slum/shackdwellers international (SDI), ossia L'Internazionale degli abitanti delle baracche, è una rete globale di comunità di base di attivisti, che conta membri in una decina di paesi in Africa e in Asia; , rete non governativa, produce nuove forme di azione politica a livello locale, introducendo forme innovative di attivismo transnazionale. Il movimento è costituito da un'alleanza di tre gruppi distinti (la SPARC- Society for Promotion of Area Resource Centres, 1984, la NSDF, National Slum Dwellers Federation, nel 1974, e la Mahila Milan, associazione di donne povere nata nel 1986), e la sua storia nasce nel 1987: le tre organizzazioni si autodefiniscono l'Alleanza, con lo stesso obiettivo di ottener ei diritti di proprietà sui terreni, abitazioni addeguate e durevoli e un accesso alle infrastrutture urbane, soprattutto elettricità, trasporti, fognature e I relative servizi in Appadurai A., The capacity to aspire: Culture and the terms of Recognition, in Culture and Public Action, Vjiayendra rao e Michael Walton, a cura di, Stanford University Press, Stanford 2004.
8 L'India è una delle più importanti economie emergenti ed è fra le prime dieci economie del mondo, con un PIL di circa 750 miliardi di dollari. Non è un paese ricco, ma sta divenendo cruciale, sebbene abbia un reddito pro capite di appena 620 dollari (3.000 in parità di potere d'acquisto), inferiore rispetto alla Cina il cui reddito pro capite è di 1.400 dollari (6.200 in parità di potere d'acquisto). In Cina il peso dell'industria (46% del PIL) è infatti superiore a quello dei servizi (41% del PIL), mentre in India il settore industriale è piccolo (27% del PIL) e poco competitivo: l'India è soltanto il trentesimo esportatore mondiale di merci. L'economia indiana è anomala rispetto a quella di molti paesi in via di sviluppo proprio per il forte peso dei servizi (53% del PIL), nei quali primeggia un'economia della conoscenza di competitività globale, oltre al terziario avanzato. Il resto del PIL nasce da un'agricoltura arretrata e di sussistenza, estremamente suscettibile al clima. La scarsa competitività di agricoltura e industria dipende in parte dalle inefficienze infrastrutturali (materiali e immateriali) e da un per corso di riforme strutturali incompleto: essi hanno avuto impatti negativi sullo sviluppo indiano e hanno limitato gli investimenti diretti dall'estero (IDE). Completare le riforme è cruciale per superare le debolezze dell'economia ed è una delle priorità del paese. Ad esempio, la difficile transizione dei lavoratori dall'occupazione informale a quella formale, dovuta in parte alle rigidità della legislazione sul lavoro, scoraggia gli IDE e contribuisce a mantenere elevata la povertà, riducendo le possibilità di molti di cogliere opportunità lavorative nel settore urbano; di conseguenza la quota di popolazione che vive in povertà è ancora superiore al 26%.
Alcuni cenni sull'evoluzione dell'economia indiana - Lo sviluppo economico indiano può essere suddiviso in due periodi. Nella fase Hindu (1947-1980) nel paese ha prevalso un modello pianificato e centralizzato e il PIL indiano è aumentato del 3,5% medio annuo, un andamento inadeguato a ridurre il gap nei confronti dei paesi più ricchi. Solo dal 1981, come per la Cina dal 1978, l'India ha intrapreso un percorso di riforme molto graduale che ha innescato una prolungata accelerazione economica: nel cosiddetto periodo Bharatiya, dal 1981, la crescita del PIL è stata pari a circa il 6% medio annuo. Nella fase Hindu, l'India perseguiva l'obiettivo di massimizzare lo sviluppo nazionale tramite la
chiusura agli scambi con l'estero e una strategia di pianificazione centralizzata e di intervento pubblico. Come spesso accade con approcci di questo tipo, le inefficienze emergono con il tempo: nel periodo fra il 1951 e il 1963 il tasso di crescita non è stato particolarmente basso (circa il 4,3% medio annuo) grazie soprattutto a situazioni non ripetibili, come il maggior utilizzo di fattori produttivi, la nascita di un sistema di imprese manifatturiere per sostituire le importazioni, e la spesa pubblica per infrastrutture e servizi di base. Nel periodo fra 1965 e 1980, invece, il tasso di crescita è diminuito al 2,9% medio annuo, soprattutto per l'esaurirsi della spinta alla crescita della pianificazione centralizzata: nel lungo periodo, la mancanza di stimoli concorrenziali ha ridotto la competitività delle imprese e l'aumento della produttività, penalizzando la crescita economica. Il rallentamento e un maggiore favore internazionale per la crescita export led innescarono un ripensamento della strategia di sviluppo. Dal 1981 il governo indiano aprì all'economia internazionale e iniziò un graduale percorso di liberalizzazione e privatizzazione, orientato da un cambio di attitudine a favore dell'iniziativa privata, senza esporre le imprese a una maggiore concorrenza. L'impatto positivo sulla produttività fu notevole, accentuato dal fatto che la semplificazione delle procedure e la riduzione delle tariffe di importazione favorirono l'incremento degli investimenti per l'ammodernamento della manifattura e dei servizi. Dal 1991 si ebbe un significativo passo avanti: il governo iniziò una più profonda liberalizzazione e privatizzazione, con la riduzione dei monopoli pubblici, un programma di ristrutturazione e apertura del capitale delle imprese pubbliche, e una più forte apertura al commercio estero e agli investimenti dall'estero. In seguito a questo cambio di strategia l'economia indiana, attualmente caratterizzata da un elevatissimo peso delle imprese familiari, ha sperimentato tassi di crescita molto sostenuti, sebbene lontani da quelli della Cina: ad esempio il tasso di crescita del suo PIL si mantiene oltre il 7% dal 2003 (approfondimento economico tratto da Chiarlone S. L'economia indiana: un mercato emergente anomalo, in ItalianiEuropei, 2006).
9 Boo K. Belle per sempre, Pickwick, Ed. Piemme, Casal Monferrato - AL, 2013, US National Book Award.
10 Movie of the 2008, by Danny Boyle in collaboration with Loveleen Tandan.

11Remotti F., L'ossessione identitaria, Edizioni Laterza, Bari, 2010.

12taken from, Behind the Beautiful Forevers, David Hare National Theatre, London, 2014 -2015.

13 the typical chawl, in Mumbai, in Davis M., Il Pianeta degli Slum, Feltrinelli, Milano, 2006.

14 read more on The Slum Sanitation Programme in Mumbai, India Vol 379 June 2, 2012 - Shaping cities for health: complexity and the planning of urban environments in the 21st century.
Mumbai's first sanitary sewer system was built in the 1860s. In 1979, a 25-year sewerage system masterplan was launched, establishing an infrastructure development strategy that consisted of a system of seven zones, each operating independently of one another. This plan was completed in 2004 and now encompasses more than 1500 km of sewers, with a total capacity of 2530 million L per day. The World-Bank-funded Mumbai Sewage Disposal Project is one of several projects launched under the plan.
Half of Mumbai's population of 11 2 million live in areas classified as slums (covering only 8% of the land area), most of which has poor access or no access at all to wastewater systems so that their residents have to use public toilets or defecate in the open. In these slums, the use of conventional water-based sewer-system infrastructure is ruled out by tenure insecurity, restricted space, and affordability considerations. Thus, an important component of the Sewage Disposal Project is the Slum Sanitation Programme (SSP). The largest programme of its kind in India, it seeks to provide access to adequate sanitation (one toilet per 50 people), by 2025, to one million people who were living in slums on municipal land in 1995.The scheme is demand-driven and premised on participation, partnership, and cost recovery, the first of which was a prerequisite for World Bank funding (matched by the State Government). It builds on the idea that a sense of ownership encourages communities to maintain the toilet blocks more effectively than would the state.Construction of the toilet blocks was allocated to two private construction firms and one large local non- governmental organisation through competitive bidding. By mid-2005, the SSP had built 328 two-storey and three- storey toilet blocks with more than5000 toilets, reaching an estimated 400 000 slum dwellers. Blocks are administered by local community organisations charging either monthly family fees or single-use fees. Fees cover regular maintenance, including water and electricity costs, with minor repairs done by the community, and the local authority undertaking major repairs. Some toilet blocks have also become community centres, providing space for teaching and meetings. Fees have allowed high standards of care to be maintained, but evidence exists that in some of the poorer settlements, only the wealthier families are able to pay the fees, with the remaining population still having to resort to open defecation.
15 exchange rate 1INR = 0,014 euro; 1500 INR = 20,32 euro.
16A conferma del movimento in cerca di lavoro, leggi: " the reality, however, is that people live where they can find work (...) but what sets Dharavi apart from other slums is its special pull factor" in Sharma K., Rediscovering Dharavi, Penguin Books, New Delhi, 2000.
17 in Vol 379 June 2, 2012, Shaping cities for health: complexity and the planning of urban environments in the 21st century: Key features of a healthy city tra cui: A clean, safe, high quality environment (including adequate and affordable housing) , A stable ecosystem A strong, mutually supportive, and non-exploitative community Much public participation in and control over the decisions affecting life, health, and wellbeing The provision of basic needs (food, water, shelter, income, safety, work) for all people Access to a wide range of experiences and resources, with the possibility of multiple contacts, interaction, and communication A diverse, vital, and innovative economy Encouragement of connections with the past, with the varied cultural and biological heritage, and with other groups and individuals A city form (design) that is compatible with and enhances
the preceding features of behaviour An optimum level of appropriate public health and care services accessible to all A high health status (both a high positive health status and a low disease status).
18 in hindi, Sister in law
19 Farmer P., Pathologies of Power. Health., Human Rights, and the New War on the Poor, University of California Press, Berkeley and Los Angeles, 2003.

20on respect on female urban poverty, the Mahila Milan association works to develop local projects

21 "however men and women are likely to have a different perspective (...).As a result, women like Kamal, says: " compare to this place, our village in Haryana is so nice and clean (...). She hopes some day that she will be able to go back", in Sharma Kalpana, Rediscovering Dharavi, Penguin Books, India, 2000, p40-41.
22 Gupta K, Arnold F, Lhungdim H: Health and living conditions in eight Indian cities. National Family Health Survey (NFHS-3), India, 2005-06. Mumbai: International Institute for Population Sciences; 2009 and Goli S, Doshi R, Perianayagam A., Pathways of Economic Inequalities in Maternal and Child Health in Urban India: A Decomposition Analysis, PLoS ONE 2013, 8: e58573.
23 Nearly 600 million people in India have no access to toilets and defecate in the open (...) and the government has pledged to make India "100% free" of open defecation by 2019, in India launches scheme to monitor toilet use, 4 January 2015,
24WHO, World Health Statistics 2010, Geneva, 2010.
25 SNEHA - Policy Brief, Community health interventions in informal settlements: reaching the most vulnerable, Mumbai, July 2015.
26 Arundhaty Roy gave the annual UCL- Lancet lecture entitled The Half-Life of Caste: The Ill- health of a Nation, Vol384 November29,2014 p.1901.

27 to a deeper lecture: "Although the analysis of gender inequality has been powerful, tensions have existed both in feminist scholarship and activism, between the power of understanding women as a homogenous subordinated group and the intersections between gender, race, class, religion, sexuality and in the context of India, caste, to name but a few (Davis, 2010; Gangoli, 2007). This has led to more complex and nuanced analyses of the ways in which inequality manifests itself and the importance of these intersections between gender and other factors in forming structures of dominance and subordination" in Davis B.M., Men, Masculinities and Emotion: Understanding the Connections between Men's Perpetration of Intimate Partner Violence, Alcohol Use and Sexual Behaviour in Dharavi, Mumbai, University College London, October 2011, pp. 25 and next.
28 Stern N., Dethier J-J., Rogers H., Growth and empowerment: making development happen, Cambridge, Mass: MIT Press, 2004.
30 Anita Jain, Patient communities reform healthcare in India, BMJ, India - BMJ 2015;350:h225 doi: 10.1136/bmj.h225 ( 10 February 2015).
31 TISS, sigla per TATA INSTITUTE FOR SOCIAL STUDIES - The Tata Institute of Social Sciences (TISS) was established in 1936 as the Sir Dorabji Tata Graduate School of Social Work. In 1944, it was renamed as the Tata Institute of Social Sciences. The year 1964 was an important landmark in the history of the Institute, when it was declared Deemed to be a University under Section 3 of the University Grants Commission Act (UGC), 1956.
Since its inception, the Vision of the TISS has been to be an institution of excellence in higher education that continually responds to changing social realities through the development and application of knowledge, towards creating a people-centred, ecologically sustainable and just society that promotes and protects dignity, equality, social justice and human rights for all.
32 "the problems of translation" in Fabietti U., Antropologia culturale, Laterza, Bari, 2005.


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