DISEASE AND DEVELOPMENT

Composed by Farooq Dawood Saati
Composed by Farooq Dawood Saati

About two decades ago, Gujrat could still be classified as a town. It was associated largely with the shrine of Shah Daulat, where barren women prayed for their fortunes to change. A modest place, Gujrat by 1998 was largely rural but its population concentration resembled urban centres. That was until urbanisation struck, changing the very face of Gujrat city as we know it.

Roads and infrastructure were built, new health and educational institutions popped up, and industry found a firmer footing. Material prosperity had arrived and it was making things better for everyone. Those living in the villages headed to Gujrat city in search of more lucrative employment.

But in the glitter of development, an ugly truth still lurks in Gujrat: more than 2,000 people contract tuberculosis every year, with more patients having contracted the disease in the past decade than ever before.

Did urbanisation have anything to do with this?

Although Gujrat is seeing many uplift projects of late, unplanned urbanisation has given birth to an extraordinary rise in tuberculosis cases in the city

UNDERSTANDING TUBERCULOSIS

As in all third world countries, tuberculosis is a major public health problem in Pakistan, too. In fact, the World Health Organisation (WHO) ranks Pakistan fifth among the 22 high tuberculosis burden countries. Gujrat reports an estimated 2,000 new tuberculosis cases every year.

The incidence of tuberculosis in Pakistan, as per the WHO, is 231 per 100,000 people. Annually, about 420,000 new cases are reported. The WHO also claims that the incidence of tuberculosis in Pakistan is 231 per 100,000 while its prevalence is 350 per 100,000 and the yearly occurrence of sputum positive cases is 80 per 100,000.

Tuberculosis is a disease that typically exists in low-income localities — the WHO explains that poverty and overcrowding are major factors that contribute to the incidence of tuberculosis. And because it is contagious, it spreads from person to person when people who have active tuberculosis cough, spit, speak or sneeze in close quarters.

“One person with tuberculosis can infect up to 10 to15 other people through close contact over the course of a year,” claims the WHO on its website. “Without proper treatment up to two-thirds of people ill with tuberculosis will die.”

But tuberculosis is also preventable and curable. To pinpoint one or two factors as causing tuberculosis would be erroneous. There is a combination of factors at play when it comes to tuberculosis, which are linked with space constraints as much as the immediate and atmospheric environment. Low-income localities are often the worst-hit simply because the majority of contributing factors to tuberculosis are often present in the vicinity.

EVOLUTION OF GUJRAT

If the 1990s was to spell an end to Gujrat’s status as a rural area, the beginning of the 2000s would witness the mushroom growth of built architecture [see Map 1]. And as the town turned into a city, urban green spaces, vegetation and water bodies were all reduced as well.

Although city planners started off with a blank slate, the haphazard and often irrational development of labour settlements has resulted in very high population densities in these colonies. Squatter settlements and slums have proliferated but there aren’t enough jobs to cater to everyone.

Consider the following: in 1990, only six percent of the total land of six union councils of urban Gujrat was used as built-up area while 69 percent of the land was under vegetation cover. Back then, only 22 percent land was barren while water coverage was at three percent.

By the time the year 2000 rolled in, built-up land use increased to nine percent while vegetation cover decreased by nine percent. Water bodies decreased by two percent (although they regained one percent in 2005). Barren land increased by eight percent (although it decreased again in 2005, 2010 and 2015 by 10, five and three percent respectively). Without a doubt, increasing urbanisation meant that agriculture and barren land in Gujrat city had decreased significantly from 1990 to 2015. Water, too, decreased in 2000 as compared to 1990.

But while this was happening, more and more people from villages of the district as well as migrant labour from elsewhere began coming to Gujrat in search of gainful employment. This meant that there was a housing problem in Gujrat. New housing did start coming up but it was inadequate to meet the new housing requirements. As a result, the few labour colonies that existed became crammed since many workers began sharing the same residential space.

But not only were these colonies brimming with great numbers, many of them also had health and sanitation issues. Since tuberculosis is contagious, if one labourer caught the disease, the many others in the same quarters would also be more likely to contract tuberculosis. And as we discovered, this was precisely the case.

RESEARCH METHODOLOGY

Map 1: Over a period of 25 years, vegetation cover has drastically reduced in Gujrat
Map 1: Over a period of 25 years, vegetation cover has drastically reduced in Gujrat

When we planned on conducting a study, we decided to focus on the spread of tuberculosis and its relationship with ecological indicators of urban areas of Gujrat City.

Since urban sprawl has serious impacts on human health, including mental and physical, we decided to map out how many cases were emerging and from where. This would give us the distribution of tuberculosis in the urban areas of Gujrat city.

Then, we superimposed these results with ecological data — urban green spaces, vegetation and water bodies — to see what kind of impact ecology has with the proliferation of tuberculosis. This involved using satellite imagery to ascertain the various kinds of spaces. Did their presence reduce the incidence of tuberculosis or did they make no impact?

It is crucial to understand that the solution to controlling the tuberculosis menace is multifaceted. It involves the government, the building authorities, labour departments, and of course, the health department, among others.

We then tallied satellite imagery with what people on the ground had to say. Towards that end, we conducted a survey across eight union councils in Gujrat. In each union council, we filled 40 questionnaires, giving us a total of 320 responses. All satellite images were snapped in the month of March (spring season), when vegetation cover is at its peak.

WHAT DOES THE DATA TELL US?

Age and sex pyramid of TB patients control programme | Data source: Author Survey
Age and sex pyramid of TB patients control programme | Data source: Author Survey

When we returned from the field, we had a bank of information that needed to be sieved through. We decided to make different breakdowns of what the data was showing.

The Madina union council possessed the highest number of tuberculosis cases among all eight union councils. This was followed by Adhowal and Kanjah. All three of these union councils are interconnected and each displays a high incidence of disease. In fact, the highest incidence of disease was found in Kanjah (6.9 per 1,000 people) followed by Adhowal (5.2) and Sabu Wal (4.2); Kalra Banta has the lowest incidence (0.5) rate, followed by Chak Sada (1.1) and Moinuddinpur (1.5).

One simple way to divide the data is by sex. Among the key outcomes was that more women were infected than men in the 14-49 age bracket from 2013-2016. Girls and women in the age bracket 15-24 reported the highest incidence of tuberculosis (27.27 percent) while the highest incidence for men was in the age bracket 25-34 (33.56 percent). The lowest recorded occurrence among both girls and boys was in the age bracket 10-14 (4.10 and 4.54 percent respectively).

The reason for these age-sex differences may be attributed to the fact that not much attention has been paid to the diet and health of girls in third world countries. Young, unmarried girls suffer from malnutrition due to misunderstood concepts of dieting in order to remain slim. But this causes deficiency of immunity, and therefore, these girls are vulnerable to disease, especially the contagious ones.

Meanwhile, young, unmarried men in the age bracket 21-34, in addition to suffering from problems associated with unemployment, also suffer from a lack of self-care and an improper diet. Many of these young men often lose hope, becoming addicted to various destructive habits — smoking is among these. Coupled with poor diet, this factor multiplies the likelihood of contracting tuberculosis.

A total of 70.54 percent of tuberculosis patients whom we interviewed revealed that they lived in shared accommodations. Unmarried women in Gujrat often share rooms but it’s the men in the 25-34 age bracket who are a matter of concern. They constitute the earliest working class in the city and have had to share their accommodation with co-workers due to poor economic conditions. This creates adverse social and ecological conditions, leading to the proliferation of infectious diseases such as tuberculosis.

Another way to read the data was in terms of how many tuberculosis patients are dependent on someone else. The questionnaire survey data reveals that women who are dependent tallied 74.27 percent while men were only 25.73 percent. The highest percentage of dependents among women was recorded in the 21-30 age bracket, 33 percent. Among men, those in the 60+ age bracket are most dependant; they total about 27 percent.

As in other third world countries, dependency on the family system in Pakistan is not unusual. Traditional social norms make it acceptable for women, children and the elderly to be dependent on their families if they contract a disease. In Pakistan, joint family systems include grandparents, uncles, aunts and cousins, who share available resources such as food, finances and the like. Traditional bondage and scant resources, thus, adversely impact the genuine and special needs of some members of the family, particularly those in urgent need of medical attention and care.

Since tuberculosis is a contagious disease, if one labourer caught the disease, the many others in the same quarters would also be more likely to contract tuberculosis. And as we discovered, this was precisely the case.

One of the questions we asked our respondents was how often they ate meat as part of their meals. Patients who consume meat once in a month have shown more vulnerability to tuberculosis, thereby indicating the impact a healthy and balanced diet has on remaining free of disease. Many of these people were unemployed and in the 15-34 age bracket. In other words, poverty tends to aggravate disease because most patients can only afford to eat meat once or twice in a month.

Then there was the question of who has at least one tree in their home. Those without a tree at home are most vulnerable to contracting tuberculosis — thus signifying how ecology plays a role in combating the disease. One of the other matrices we worked on was the distance to a hospital and to a public park from a patient’s house. We discovered that only 29.37 percent of respondents live three to six kilometres away from a hospital while 43.36 percent respondents resided 10km away from a public park. Dig deeper and one discovers that public parks in Gujrat are not fulfilling the needs of the population.

To sum up: the incidence of tuberculosis depends on social, economic and demographic factors. These three intersect at some points, making the problem even more complex. And the most vulnerable tend to be in the 15-45 age bracket. Women and men have a slight difference in the 25-34 age bracket, with men being more infected than women. Patients living in a family size greater than seven persons are more infected, particularly in the 15-35 age bracket. This largely boils down to congested residential quarters. Small family sizes, therefore, are more conducive to improving quality of life.

WHAT IS NOT TO BE DONE

The graph shows some socio-economic and demographic factors that impact the incidence of tuberculosis
The graph shows some socio-economic and demographic factors that impact the incidence of tuberculosis

The global experience of urbanisation has been one that is laden with many obstacles. The better urbanisation models have ensured that people building a new city are prioritised, that they have healthcare, adequate housing, and a balanced diet. But there are many other cases where the process of urbanisation has created dichotomies between the haves and have-nots, between those who construct a city with their bare hands and those who profit from it. The case of Gujrat is no exception to the rule.

Today, the city of Gujrat and indeed, the district of Gujrat, boasts industrial activity across many different sectors. Tyres and tubes are made here, textile is a huge draw, porcelain, tableware, and ceramics are becoming more in demand, and there is no shortage of electronics manufacturers either. Then there is the production of animal feed, dairy products, and even rice bran oil.

Undoubtedly the urbanisation of Gujrat city over the past two decades has had a positive impact — but only if you consider one half of society. There has been some job creation, which has led to migration of labour from rural areas to urban. But ultimately, the state of the workforce defines how successful the urbanisation project in Gujrat has been.

Although city planners started off with a blank slate, the haphazard and often irrational development of labour settlements has resulted in very high population densities in these colonies. Squatter settlements and slums have proliferated but there aren’t enough jobs to cater to everyone. Not only are resources scarce for the working classes, those that exist are often inadequate to meet the demands of the populace.

In a sense, therefore, the government has left the labouring classes of Gujrat to fend for themselves. Even in a small city, only the fittest will survive. Meanwhile, the consequences of the government’s abdication from responsibility are manifold.

Consider this: if the normal work rate is 100 rupees per day, excess unemployed labour means that employers can drive the daily wage down. And there is nothing that the labourers can do about it. But this also means that workers now have to fight the extra battle against inflation. Throw a contagious disease such as tuberculosis in the mix and what we have is ordinary people struggling to meet not just everyday expenses but medical ones, too. Development has failed this strata of society.

But with so much having changed over the past two decades, it is safe to say that demographic factors and the ecology of the city are directly impacting the rising incidence of tuberculosis in Gujrat. Restricted incomes and an unbalanced lifestyle are common among tuberculosis patients. How do we escape this vicious cycle?

It is crucial to understand that the solution to controlling the tuberculosis menace is multifaceted. It involves the government, the building authorities, labour departments, and of course, the health department, among others. It requires a rethink at policy level: how do we integrate the various measures taken to counter tuberculosis and construct a holistic policy?

The building blocks of the fight against tuberculosis will, of course, be in the implementation of policies framed by the WHO and the National TB Control Programme. But setting up a national tuberculosis research centre must be taken up on a priority basis. And vulnerable union councils need to be targeted with preventative measures — chief of them being the revamp of the basic health unit structure in these areas.

Costs are another concern and the government ought to play its due role in ensuring that the downtrodden are not left to the dogs because they don’t have money to pay for the healthcare they need. Towards that end, private clinics should also refer patients displaying symptoms of tuberculosis to basic health centres for diagnosis and treatment.

One of the big challenges in the treatment of tuberculosis is record-keeping. Private practitioners often don’t maintain records but they need to be bound to this practice. Record keeping of case management practices, including diagnosis and treatment outcomes, is currently inadequate. Development and implementation of standardised operational tools and a regular monitoring system is required to improve the performance and quality of services regarding tuberculosis.

But, ultimately, disease can only be divorced from development if the government prioritises its citizens’ wellbeing over other objectives.

The writers are associated with the University of Gujrat. Research for this project was funded by the Higher Education Commission

Published in Dawn, EOS, June 15th, 2018

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