Death is the Only Option for Us! Unveiling Health and Healthcare Crises Among Slum Dwellers in Guwahati Metropolitan City,India

The Context

The ever-growing issues and challenges faced by people living in slum areas are now gaining attention from policymakers and scholars across disciplines. A series of studies conducted in and across the slums in the low- and middle-income countries evidently demonstrates that the slum dwellers’ health and healthcare situations are not only affected by poverty but also by intimately shared physical and social environments.^1–5 These shared physical and social environments often lead to the transmission of infectious diseases like tuberculosis, respiratory infections, and diarrhoea. Moreover, vector-borne diseases such as dengue and malaria are often highly prevalent among slum dwellers due to inadequate water disposal and stagnant water.^6,7 These infectious and non-infectious diseases are also often exacerbated by the lack of water, sanitation, and hygiene (WASH). It has also been explored that this issue of WASH has to be borne by women and girls due to gender norms, and this led to compromised health.^8,9 A study conducted in Ghana explored the significant prevalence of chronic kidney disease among slum dwellers. ¹⁰ Similarly, studies found a high prevalence of hypertension among slum dwellers in Lagos, Nigeria, ¹¹ Southern Ethiopia, ¹² and Kenya. ¹³ Moreover, the burden of musculoskeletal disease is also highly prevalent in slum dwellers of lower- and middle-income counties and has been identified as a significant cause of impaired subjective well-being and functioning among slum populations. ¹⁴ However, studies mostly reported that economic inequalities in income have emerged as a significant cause of severe health and healthcare vulnerabilities among slum dwellers across low- and middle-income countries.^15–20 However, their health issues remained unaddressed.^21,22

Despite the heterogenous nature of slums across the lower- and middle-income countries, slum populations are facing similar issues in access to better healthcare services, and India is no exception. Factors ranging from poor housing, ²³ lack of water and sanitation,^9,24 income inequalities,^25,20 and lower levels of education,^26,27 to lack of proper government health facilities or policies,^23,28,21 poor community participation, lack of awareness, frequent migration, and loss of daily income ²⁹ have significantly increased health and healthcare issues among slum dwellers in India. Moreover, the prevalence of noncommunicable diseases across all age groups in slums suggests a high future burden of illness among slum dwellers. ³⁰ Indeed, slum dwellers in India carry the double burden of diseases. ³¹ However, despite that, slum dwellers in India prefer private health facilities over the public. For instance, in slums of Pune, 60% of the dwellers sought treatment from private medical facilities for their ailments, and slum dwellers are often dissatisfied with public healthcare services and hence visit private facilities. Poor quality of care, long distance, and long waiting times, along with the negative attitudes of healthcare workers, are the main barriers with regard to healthcare services. ³² A study conducted in four cities—Jaipur, Ludhiana, Mathura, and Ujjain—explored slum dwellers’ high preferences for private health facilities, though the healthcare facilities are costly in private hospitals. ³³ Slum dwellers report that higher education and income significantly influence their choice of private hospitals. However, healthcare insurance schemes have failed to include the urban poor in India.^34,35 Thus, the failure of the state in implementing an inclusive healthcare policy for slum dwellers leads to poor health outcomes. ²²

Although this existing evidence showed the health and healthcare vulnerabilities among slum dwellers across the lower- and middle-income countries, studies are mostly objectivist in nature. Earlier studies have failed to capture the varied subjectivities of health and healthcare vulnerabilities among slum dwellers. Moreover, despite the growing demands for in-depth qualitative understanding of public health,^36,37 research concerning slum dwellers and their health is mostly confined to the reductionist model and fails to accelerate complex “theories to account for the whole person within their socio-historical-cultural environments”. ³⁸

Given the context, in this study we critically engage with the health and healthcare issues among slum dwellers in the Guwahati metropolitan city in India and ask: How do the slum dwellers in Guwahati manage their healthcare issues? What makes their health and healthcare issues vulnerable? Why are they still struggling to take care of their health issues despite the existence of state-funded public healthcare centers like the Guwahati Medical College and Hospital (GMCH) in Guwahati? In this article, we aim to answer these questions.

We unfold the paper as follows: in the second section, we placed Guwahati and its slums in the context of this study and elucidate the present situations of slums and their dwellers in Guwahati. The next section outlines the methodological framework of the study. The section detailed the processes of “narrative inquiries” into the health and healthcare crisis among slum dwellers in Guwahati. In the subsequent sections, we analysed the results, which we presented in four thematic sections. Finally, the concluding section discusses the findings and reflects on the policy implications for the health and healthcare planning for the slum dwellers in Guwahati.

Guwahati and Its Slums in Milieu

Guwahati's growth as a city began during the colonial era. In the post-independence era, Guwahati has seen an unprecedented surge in population growth, largely driven by in-migration at various points in its history.^39,40 Notably, the research participants of this study are migrated from different areas of Assam's Dhubri district in search of jobs and settled in Guwahati for more than a decade. According to the 2001 census, Guwahati city has a total population of 809,895 under the Guwahati Municipal Corporation and a slum population of 156,831 in Guwahati Municipal Corporation-covered areas. ⁴¹ The number of slum dwellers in Guwahati has steadily increased, from 19.4% of the city's population in 2001 to 163 identified slum pockets by 2017 under the Pradhan Mantri Awas Yojana. Earlier surveys found 20 to 93 slums between 1997 and 2013, which shows that urban poverty has been steadily rising.^40,42,43

Recent studies conducted in Guwahati show that, overall, the well-being of slum dwellers in Guwahati city is severely deplorable.^44,45 The Basic Services to the Urban Poor (BSUP) Programme launched the Jawaharlal Nehru National Urban Renewal Mission in 2005 to support cities and towns in developing housing and infrastructure for the urban poor and slum dwellers in 65 selected cities, including Guwahati. However, the BSUP has largely failed to implement its intended improvements in Guwahati's slums, leaving residents to live in overcrowded and unhygienic conditions with inadequate ventilation and substandard housing. ⁴⁶ Moreover, a study reported that limited access to potable water, deficient sanitation facilities, and inadequate hygiene practices further jeopardize the well-being of the slum population in Guwahati. Severe health issues such as stomach-related ailments, including pain, constipation, bloating, heartburn, ulcers, nausea, vomiting, liver and intestinal issues, urinary tract infections, and musculoskeletal issues were significantly high among slum dwellers in the city. During monsoon season, infectious diseases such as diarrhoea, viral fever, and malaria significantly increase among the slum population due to poor sanitation and contaminated food, including the consumption of contaminated water. ⁴⁷

Youth for Unity and Voluntary Action and the Office of Emergent Practice ^{40 (pp.18,36-37)} also conducted a study on Guwahati's informal slums and found that the slum population in the city is systematically excluded from the city's planning processes and severely suffers from the lack of basic amenities like safe drinking water and sanitation. Moreover, the temporary housing structures and the absence of land tenure records make these communities vulnerable to forced evictions by the administration. Frequent or threatened evictions force residents to relocate regularly, which often results in the loss of legal documents or personal belongings due to floods, erosion, and regional conflicts. In such situations, slum dwellers belonging to the social categories like the Scheduled Castes (SCs) and Scheduled Tribes (STs) ¹ are more vulnerable.

Although earlier studies and surveys have highlighted some of the issues facing slums and their dwellers in Guwahati city, there is a dearth of studies specifically focusing on issues in access to healthcare and challenges facing slum dwellers in Guwahati. Given the context, in this study, we critically engage with slum dwellers’ health issues and their everyday challenges in access to healthcare within Guwahati and try to suggest some policy implications for improving the healthcare conditions among slum dwellers in the Guwahati metropolitan city.

Narrative Inquiry: On Methods

We chose “narrative inquiry” ⁴⁸ as a method to bring a nuanced understanding to healthcare issues among slum dwellers in Guwahati. Specifically, using narrative inquiry, we tried to explore the very individual experiences of health and healthcare challenges that the slum dwellers in Guwahati faced and investigated how it shaped slum dwellers’ understanding of their health and healthcare crises. Research participants for this study were selected from Dhirenpara slum, a notified slum declared by the Guwahati Metropolitan Development Authority. Research participants were part of our project on “Life and Livelihood of Slum Dwellers in Guwahati City.” Upon our request, a total of eight female research participants agreed and provided both their verbal and written consent for in-depth interviews. Among these women, three belong to the Hindu religious community and come under the SCs category, and five other women belong to the Muslim community. They belong to the age group between 23 and 55.

Currently, all of them are working as house help and rag pickers within the vicinity with very limited income. All our interviewees are female because they were more available, if not all the time, than their male counterparts during our study. Moreover, during conversations, we explored that they are more experienced in terms of their negotiations with healthcare institutions like the GMCH. All the interviews were conducted during different times from November 2023 to October 2024, as per the research participants’ convenience. The time taken for in-depth narrative interviews varies from participant to participant and was based on the critical storytelling processes as well as the content.

Throughout the storytelling processes, we also looked at how their lived experiences of healthcare issues influenced their health-seeking behaviors and how it shaped the way they perceived their health. Given the context of their socio-religious backgrounds, we tried to understand how they perceive their social backgrounds while constructing narratives about health and healthcare crises and how they were constantly negotiating their identities. Although these identities were narrated differently, they emerged collectively, which they expressed in terms of marginality.

All the interviews were conducted in a respectful and humanitarian manner, and both verbal and written consent have been taken to record their narratives, and pseudonyms have been used to protect their identities. However, we retain the title to reflect their socio-religious belongingness as it often intersects with their healthcare outcomes. Indeed, throughout the process of narrative inquiries, we examined their varied experiences of health issues and healthcare crises. Moreover, in terms of reflexivity, we turned the lens back onto ourselves as “researchers” to take responsibility for our own situatedness within the research process and “the effect that it may have on the setting and people being studied, questions being asked, data being collected, and its interpretation”.^49(p.220) Finally, we used “narrative analysis”^50,51 to analyse the collected data.

Revealing Health and Healthcare Issues Among Slum Dwellers in Guwahati

Concluding Thoughts

In this article, we attempted to understand how slum dwellers in the Guwahati Metropolitan city in India suffer from layers of vulnerabilities in access to healthcare in their everyday lives. It was found that their health and healthcare crises emerge from factors which include the poor economic conditions and occupational vulnerabilities, lower level of education, marginalized social background, and social, systemic, and infrastructural inequalities and inequities that exist within the public healthcare system. Through narrative inquiries, we explored how all these factors intersect and exacerbate their health and healthcare issues and make their lives more vulnerable. These results are also consistent with those observed in previous studies.^1–5

We explored how healthcare often might be free, but the indirect costs of healthcare conditions are too high, which significantly discourages them to even use public healthcare services. Similar findings have also been reported in studies conducted in low- and middle-income countries.^15–20 Moreover, research participants pointed out that due to poor education and communication barriers and lack of knowledge about the functioning of healthcare institutions like GMCH, in this case, deter their visits to doctors further. Even though they visit, they always had to bring along someone more experienced with hospital procedures, which significantly increased their financial burden and discouraged them from seeking necessary medical care at public healthcare institutions. This highlights how inaccessible public healthcare is to the poor and illiterate slum dwellers in Guwahati. What is interesting to note is that the system too is socially discriminative and iniquitous. However, this has been a prolonged problem of the Indian public healthcare system, as showed in other studies.^65,66 Indeed, visiting and getting treatment from “big” hospitals like the GMCH were often challenging for the slum dwellers, who belong to the lowest social and economic background.

Furthermore, the assertions made by research participants regarding the connections between public healthcare centers and private pharmacies are crucial for understanding how public hospitals in Guwahati, such as GMCH, enable private medicine companies to expand their market and diminish access to better healthcare for impoverished individuals, including slum dwellers. Such narratives underscore the systemic commodification of the public healthcare system in India. These assertions significantly reflect how the public healthcare system in India maintains alliances with the capitalist politics of disease and poses a challenge to the goal of universal health coverage, which systematically excludes economically vulnerable populations.^67,68 Even though the government says healthcare is “free” and supports universal health coverage, research participants’ stories show that the poor condition of public healthcare forces them to spend their own money on health, often leading them to use private services. Indeed, Indian policies have failed to bring justice to the urban poor, including slum dwellers, ²⁸ and have forced them to live on the margins with numerous vulnerabilities. ²¹

We learned from the field that while both access to healthcare facilities and the quality of public healthcare are things that require attention from academia to policy intervention, the burden of healthcare on people like slum dwellers is what is of critical concern. What is crucial here is also to understand how the burden of healthcare have taken a toll on slum dwellers. Simultaneously, the already overburdened public healthcare system has not been able to address the issues of equity, increasing commercialization, injustice, trust, and lack of information dissemination as and where required. While it is very difficult to dispel people's negative perception, some efforts towards a more humane approach towards people who are poor and recognizing the lacunae of a poor system are essential to address.

Indeed, based on the field insights, we argue that understanding the ingrained disparities that impoverished slum dwellers experience within the urban landscape is a prerequisite to addressing their health and healthcare vulnerabilities. We also suggest policymakers must prioritize slum dwellers’ health issues in national health policies. Although an effort has been made under the National Urban Health Mission to tackle the healthcare issues of the slum dwellers, we specifically suggest provisions such as the appointment of community health workers within slum areas. The urban planning commission should facilitate and encourage community-driven health interventions to address the issues of health care among slum dwellers. Studies^69,70 have already demonstrated how community-driven health intervention in slums like Dharavi in Mumbai, India, and in Rawalpindi, Pakistan, improves healthcare issues among slum dwellers. However, in so doing, both adequate funding and political intervention would be required. Considering their economic vulnerabilities, mobile health clinics and modern technology like geographic information systems should be set up in areas of slums. Finally, we suggest context-specific solutions for health issues among slum dwellers. The model that fits for Dharavi, Mumbai, or elsewhere in the world may not fit in Guwahati due to its regional context and the background of its population. In so doing, we suggest using narrative inquiries to capture local nuances, which will give more critical insights into framing inclusive healthcare policies for slum dwellers in Guwahati. Thus, achieving health and healthcare equity for slum dwellers is not just an elusive goal; it is a tangible reality that must be supported by a holistic policy approach, which also includes empathetic and ethical behavior from healthcare professionals towards marginalized populations.