Running head: Along the Old Mahabalipuram Road 1

Along the Old Mahabalipuram Road: Integrating Biosocial Approaches to Support State Healthcare Systems in Caring for Displaced Persons in Tamil Nadu, India

Brenda Wilmoth Lerner

Case Studies in Global Health: Biosocial Perspectives

Harvard University

December, 2012

Running head: Along the Old Mahabalipuram Road 2

After the South Asian tsunami in 2004, over fifteen thousand surviving coastal fishermen and their family members in the South Indian state of Tamil Nadu were relocated inland to areas along the Old Mahabalipuram Road (OMR), a road originating in the bustling city of Chennai that follows the coastline south along the Bay of Bengal to the ancient community of Mahabalipuram, home of coastal temples declared UNESCO

World Heritage sites. Most of these fisher families were housed in the slum tenement buildings of Kannagi Nagar, a neighborhood about 11 miles (18 kilometers) south of central Chennai along the OMR, where they were met by additional families that were relocated to Kannagi Nagar after the inner-city makeshift dwellings where they resided were razed to make way for modern development. The term slum used here implies either a makeshift, open, or structured residence, but without access to any or all essential elements including potable water, a working sanitation system, and/or reliable electricity.

While the Old Mahabalipuram Road has transformed since the tsunami into Chennai's burgeoning technology corridor and the area along the coastal road has become a real- estate hot spot, Kannagi Nagar has grown in population only, and now houses roughly

80,000-100,000 people crowded into a space of about 99 acres (40 hectares). As a result, many people have chosen to leave Kannagi Nagar and have formed slum settlements along the banks of nearby waterways including the Okkiyam Maduvu and Cooum River, sometimes only to be forcibly relocated back to Kannagi Nagar as river beautification or development projects begin. In this paper, the author will explore how risk factors for social suffering and disease are amplified in Kannagi Nagar, and how India's existing public and private health systems are not meeting the needs of this vulnerable population of internally displaced persons. Unintended consequences of relocating these people will Running head: Along the Old Mahabalipuram Road 3 be outlined, along with how this affects the health and functionality of community members according to age and gender. Social factors that amount to structural violence will also be discussed, including elements that render the existing healthcare infrastructure inaccessible or ineffective. And finally, a plan for accessing specific needs and improving access to healthcare for the residents of Kannagi Nagar will be presented for consideration, using a type of biosocial methodology that the author labels a "point- horizontal approach," and which considers the local world of the Kannagi Nagar population, complements existing systems, provides incentive for community engagement, and encourages accountability from the local and state governments.

India is a rapidly developing lower-middle income country and the world's most populous democracy. With a bicameral parliamentary form of national government, India is divided into 28 states, each with an elected legislative body that shares power with the central government. Within the state, local governments include municipal bodies that manage city governance in addition to panchayats, which manage rural communities and are the smallest form of village government. Of India's 1.24 billion people, almost one third (30%), or about 400 million people, fall below India's national poverty line and 69% of workers earn less than U.S. $2.00 per day (World Bank 2012). Most of India's population lives in rural areas, but increasingly, people are migrating to cities in search of employment and educational opportunities. Often, these newcomers to India's cities take residence in informal or makeshift housing in densely crowded slum areas within the city or just outside its boundaries. When the land upon which the slum rests increases in value or is slated for development, the slum is often razed and its residents are relocated, with or without physical and monetary assistance from the state. In the South Indian state of Running head: Along the Old Mahabalipuram Road 4

Tamil Nadu, the state, along with the city of Chennai created the Tamil Nadu Slum

Clearance Board (TNSCB) in 1970 for the purpose of systematically improving

Chennai's slums or clearing them and providing relocation assistance to their residents.

Since it's creation, the TNSCB has built 105, 000 flatted tenements (tenement apartments) in Tamil Nadu. One of the largest of these tenements is Kannagi Nagar, the first phase of which included 3000 apartments that were built in 1998-2000 south of the city of Chennai in coastal marshes along the Old Mahabalipuram Road. Along with a scheduled increase in the number of units built in Kannagi Nagar, two events resulted in a large and rapid scale-up of the project: the adoption of a national plan that targeted

Chennai for slum clearance, and the 2004 Indian Ocean tsunami. Declaring that Chennai would be "Slum-free by 2013," the Jawaharlal Nehru National Urban Renewal Mission project, mostly funded by the Indian national government, doubled the size of Kannagi

Nagar (TNSCB 2010, p.4). By 2005, and after 15,000 survivors of the tsunami joined the displaced slum dwellers in Kannagi Nagar, more than 80,000 people were crowded into its current configuration of 15,656 tenements (FLLRC and CRF, 2010, p.3).

Despite the intention to provide an alternative to the slums, the people of Kannagi

Nagar are exposed daily to an environment that fosters social suffering on par with that often experienced by refugees or internally displaced persons (IDPs). As medical anthropologist Arthur Kleinman notes, suffering arising from the effects of political, economic, and institutional power affects more than the person involved; it also affects families and entire communities, thus becoming a social experience (Kleinman 1997, p.ix-x). Kannagi Nagar residents experience social and economic isolation, along with separation of families, as there exists only one bus stop in Kannagi Nagar to link the Running head: Along the Old Mahabalipuram Road 5 peripheral tenements with the city center, and buses travel the route to central Chennai and return only once daily. Men seeking work in Chennai often cannot make the return journey in one day and resort to staying in the city for extended periods. Kannagi Nagar residents experience loss of livelihood, as few opportunities exist for fishing or marketing of goods in or near the tenement. Residents report that social stigma associated with

Kannagi Nagar as a place known for filthiness and thieves reduces their chances of being hired as housekeepers, an occupation many women held in the city before they were displaced to Kannagi Nagar (PUCL 2010, p. 33-35). Residents experience loss of community, as disparate groups of displaced persons from 62 different locations are housed closely together and often speak different languages, in this case mainly Tamil,

English, Telugu, or Hindi. They experience overcrowding and lack of privacy, as families live together in one-room tenements averaging 150 square feet (FLLRC and CRF, 2010, p.10). They experience increased risk of disease, particularly waterborne and vector- borne diseases, as little improved sanitation exists within the tenements and a large, sewage-polluted and often stagnant waterway, the Buckingham Canal, flows alongside

Kannagi Nagar and often floods with seasonal monsoons. According to the United

Nations High Commission on Refugees (UNHCR), persons that have been displaced "in cases of large-scale development projects, which are not justified by compelling and overriding public interests" fall into the category of IDPs, as well as those displaced by natural disaster (UNHCR 2001, p.3-4). As such, according to existing WHO and UN policy, an argument can be made that Kannagi Nagar residents meet the criteria for IDP status, and are thus entitled to a durable solution for health care as well as housing, with Running head: Along the Old Mahabalipuram Road 6 the government taking the lead to promote sustainable solutions to their suffering

(Brookings 2010, p.32).

Kannagi Nagar is not functioning as a viable community and an alternative for people displaced by development or disaster in Chennai. In fact, the purposive action of the TNSCB in creating Kannagi Nagar has resulted in unintended negative consequences.

It is an ironic fact that without adequate investment in the infrastructure of Kannagi

Nagar, the tenement has become what it was intended to replace, a slum. With the expansion of city boundaries southward in late 2011, Kannagi Nagar now lies just within the city limits of Chennai, and its residents must therefore re-figure into estimates of

Chennai's slum population, which has reached 1.25 million persons (Census of India,

2011). Other unintended consequences disproportionately affect the well being of children, the elderly, and women. Some elderly Kannagi Nagar residents abandoned their apartments and returned to makeshift housing near riverbanks, due to their inability to navigate the steep tenement stairs when attempting to access clean water from outside pumps. Other elderly or disabled residents remain inside their apartment, dependent upon family members or others for water due to the arbitrary assignment of an upper-level apartment. Other residents return to slums along the waterways because the occasional flooding of the riverbanks is easier to anticipate and cope with than the continual standing water within areas of Kannagi Nagar resulting from lack of drainage from the marshes.

Children attend school less frequently once they are relocated to Kannagi Nagar, and relocations are accomplished without regard to the school calendar. There are three primary schools and only one secondary school within the tenements. According to Child

Rights and You, an Indian NGO and advocacy group that operates in Kannagi Nagar, the Running head: Along the Old Mahabalipuram Road 7 high dropout rates are largely attributed to the disruptive cycle of poor health, absenteeism, and disease risk from lack of clean water and sanitation. The conditions of

Kannagi Nagar are especially difficult for women. Instead of safety and security, the isolated and crowded conditions of the tenements have fostered gang-style criminal activity that results in thefts of food and money, and also sexual violence against women, especially for those living alone whose husbands work in the city. Suicide is increasing in

Kannagi Nagar, and most suicides there reported to the police are among women ages 25-

35 (Neeraja 2009). Giving birth and caring for children is complicated by the lack of a primary healthcare center or hospital in Kannagi Nagar. The nearest government healthcare center is three kilometers (1.8 miles) away, but with only two full-time staff members, it does not provide maternal health services (FLLRC and CRF, 2010, p.20-21).

Kasturba Gandhi Hospital in Triplicane is the nearest government hospital that provides

24-hour maternal health services. At 20 km (12 miles) away from Kannagi Nagar, it requires an expensive taxi fare or an auto-rickshaw ride of about an hour to reach the facility. As a result, while the state of Tamil Nadu has made much progress in lowering maternal mortality rates within the past decade by encouraging women to give birth in an institutional setting or in the presence of a skilled birth attendant (Padmanaban 2009), the women of Kannagi Nagar usually give birth unattended by a skilled healthcare worker and make the journey to Kasturba Gandhi Hospital only when complications arise (PUCL

2010, p. 44-45).

Especially relevant to the environment experienced by the people living in

Kannagi Nagar is American medical anthropologist Paul Farmer's description of the global resurgence of tuberculosis and a comparable situation in central Haiti, where an Running head: Along the Old Mahabalipuram Road 8 affected population also marginalized by geography and poverty experiences inequities in access to healthcare and the ability to earn a livelihood. Farmer equates such conditions to structural violence: "the poor have no options but to be at risk for TB, and are thus from the outset victims of structural violence (1997, p. 349). Rather than relying on the two biological factors that are most often used to explain the resurgence of tuberculosis

(HIV and increasing bacterial resistance), Farmer argues that TB also remains a social disease, and that forces including poverty, economic inequalities, and racism play a role in the re-emergence and continuing burden of tuberculosis (1997, p. 347). Stigma could also be added to this list of forces, as it discourages people in India, especially women who fear being ostracized from their families, from seeking diagnosis or treatment. As

TB remains a major cause for mortality and morbidity in India, the disease is highly under-diagnosed in crowded living areas such as Kannagi Nagar. One estimate published in a 2011 study puts the likely prevalence of tuberculosis in males residing in Chennai slums at 863/100,000 people, nearly twice that of the rest of Chennai's male population,

437/100,000 people (Sakdapolrak 2011, p.87). Farmer also links the inability of a person to comply with treatment if they are never diagnosed, as well as the inability to comply with treatment if it is not made easily available to vulnerable individuals, both situations relevant to Kannagi Nagar, as additional forms of structural violence (1997, p. 349).

In order to evaluate the causative factors for the lack of effective health systems in

Kannagi Nagar and to offer a workable solution, it is necessary to first consider the political and economic structure of India as a whole, initially viewed through a brief and recent historical perspective. The British East India Company, which was established for the purpose of exporting goods from India including cotton, opium, potassium nitrate for Running head: Along the Old Mahabalipuram Road 9 gunpowder production, tea, and spices, privately ruled India for a century beginning in the 1750s, until the British government assumed rule in 1858. The British Raj lasted for almost another century, and ended in 1947 with the partition of India into the independent states of Pakistan and the Union of India, a forerunner of the modern Republic of India.

During its two-century colonial presence in India, Britain established a widespread military presence, western-style hierarchies of bureaucracy and administration buildings, textile factories, financial establishments, a comprehensive rail system to move products to seaports, a British-style merchant economy in India's emerging states, and eventually a parliamentary system of law. The British also lent both a blind acceptance and an amount of reconstruction to the persistence of existing social patterns among the Indian people, including the caste system and strict patrimony, as it encouraged a ready and largely acquiescent workforce for their industries that was "anchored to the service of a colonial interest in maintaining social order" (Dirks 2001, p.14-15). While the early colonial focus was on industry and trade, a few scholars and practitioners eventually called for building a knowledge base for the particular medical concerns of the tropical colonies. Again, most of these calls were made for the benefit of the colonizer, as in the English physician

Patrick Manson's 1897 call for the teaching of tropical medicine "because our country is at the seat of a great and growing empire, and because tropical diseases are…widely different from the diseases of temperate climates…the only diseases about which at present the student receives instruction (Manson 1895, p.985). By 1900, the British had set up a network of colonial hospitals and dispensaries in India that were mostly staffed by European doctors. The advent of infectious disease research, surveillance, the systemized response to epidemics, and the overall discipline of tropical medicine were Running head: Along the Old Mahabalipuram Road 10 direct consequences of colonialism, however, the "archetypical European colonial design of medical services and neglect of the indigenous population" did little to relieve the suffering of India's poor (Mushtag 2009, p. 6, 14).

In its post-colonial 65 years since gaining independence from the United

Kingdom, India has mostly concentrated on building agriculture, a military, and a physical and economic infrastructure rather than growing and maintaining a functioning primary healthcare system for its people. A national health policy was not adopted until

1983, and until relatively recently it focused primarily on vertical approaches such as vaccination campaigns that were designed to respond to a specific health challenge.

During the 1980s and 1990s, India was the recipient of healthcare aid and interest from multiple countries with different ideologies, including the Soviet Union's centralized methods, and the Western neoliberal approaches that included the mandating of loans, structural adjustments, and implementing user fees. Additionally, the presence of non- governmental organizations (NGOs), whether faith-based or secular, political or apolitical, or simply humanitarian in motivation, blossomed in India during these years.

Most of these programs also featured vertical approaches designed to meet a specific health challenge rather than to shore up the existing state health infrastructure. Today,

India continues to rely on much of this structurally and ideologically disparate aid as it builds its health care systems. The necessity for India to commit more of its own resources towards healthcare infrastructure and medical personnel is strongly suggested here, regardless of the input of peripheral resources from the world community. India currently expends only one percent of its gross domestic product (GDP) on public health systems, contrasting with other lower-middle income countries such as Ukraine (3.5%) Running head: Along the Old Mahabalipuram Road 11 and Honduras (3.8%) (World Bank 2012). India also fell short of its modest goal to commit an amount equal to two percent of GDP expenditure on public health by 2010, as stated in its revised national health policy (India 2002). One result of this lack of internal investment has been the proliferation of an abundance of similar well-meaning national or state-level policies that are not realized, a situation that is defined here as "negative governmentality." Max Weber's legal authority and bureaucratic hierarchy is in place; the public health policies and objectives are clearly defined, but especially in the rural areas of India and in urban slums such as Kannagi Nagar, government hospitals and regional healthcare centers rarely function according to policy, and often do not function at all.

Medications classified as essential drugs are often not available at dispensaries; regional clinics often close due to lack of staff; the nearest hospitals often have no physicians on the premises at nighttime, and laboratory samples are often spoiled or unprocessed during frequent power outages. On the state level, another example of negative governmentality that directly affects the residents of Kannagi Nagar includes the Chennai Corporation's

(city government) failure to implement a seven-point formula for urban malaria control mandated in 1990 by the state directorate of public health (NIMR 2001, p. 188). This plan, for example, calls for environmental controls including creating drainage systems within urban marshes such as those in and near Kannagi Nagar to eliminate breeding grounds for mosquitoes. Actions (or inactions) that constitute negative governmentality on the national level include lack of adherence to the National Rehabilitation and

Resettlement Policy (NRRP) of 2007 in Kannagi Nagar that states that involuntarily displaced or resettled families are entitled to a structure consisting of at least 50 sq. meters (538 sq. feet) of space per family of four persons, and with basic facilities Running head: Along the Old Mahabalipuram Road 12 including roads, drainage, sanitation, drinking water, electricity, and access to public transport, a post office, schools, a health center, and nutritional services for mothers and children (PUCL 2010, p.21). Many of these essential facilities, including access to healthcare, are not provided in Kannagi Nagar; others are so irregular and infrequent in their availability that the tenement population cannot depend on them. A second key component of this paper, therefore, holds that any durable solution to provide healthcare for the marginalized residents of Kannagi Nagar must assist and reinforce the state in eliminating negative governmentality in order to translate policy to workable, sustainable action in the tenements. Whether the answer is a health system integrated with other parties or a stand-alone entity, a durable solution for Kannagi Nagar should be an Indian- backed system based upon Indian values reflecting viable policies that serve both individual and public health.

It is important to emphasize that Kannagi Nagar is a small geographical area on the edge of one of the fastest growing cities in India, and that along the Old

Mahabalipuram Road, thriving industries include seven technology companies within 2 kilometers (1.2 miles) in either direction of the tenements. A Pizza Hut recently opened just 500 meters (547 yards) from the Kannai Nagar bus stop, and a medium cheese pizza there costs 300 Indian Rupees, half a week's wages for a typical Kannagi Nagar resident

(about U.S. $5.50). Set amid this area of economic growth and prosperity in Chennai, one must consider the moral implications of allowing the population of Kannagi Nagar to continue to experience inequities in access to clean drinking water, healthcare, and life's basic necessities. Perhaps the people of Kannagi Nagar have been considered as socialized for scarcity because they were slum dwellers or disaster victims prior to Running head: Along the Old Mahabalipuram Road 13 arriving there. More likely is the explanation that their situation has not been seen as a top priority in an otherwise rapidly developing region. Kannagi Nagar should be considered, therefore, as a small point within a larger successful region that is ripe for an intervention to reduce these inequities. A point-horizontal approach would zero-in on this one small space, the 44 acres of Kannagi Nagar and its population, and within this area would provide a broad platform of medical and social support that would help build a healthier community. Global health physician Peter Drobac and his colleagues described an effective strategy of implementing comprehensive primary healthcare for vulnerable populations in poverty in both Rwanda and Haiti, where geographic isolation was a much more difficult obstacle to overcome than it would be than in Kannagi Nagar. Both programs were carried out with the participation and commitment of local and state governments, and the state healthcare delivery systems were strengthened in the process.

In Haiti, Drobac described a "community-based, hospital-linked healthcare model capable of delivering high-quality services in rural Haiti, which was without electricity or paved roads or modern sanitation," the early success of which, "countered immodest claims that complex health interventions…could not be delivered in resource-poor settings" (Drobac 2012). Key to this approach was including donor or grant funding to build state health infrastructure instead of an independent entity, or essentially, working with the government instead of parallel to it. Community involvement is also a key strategy.

Similarly, India's state government, a local council (from the former panchayat before the tenements were incorporated into the city of Chennai), and other committed actors could work together to build a hospital/healthcare center within the tenements to Running head: Along the Old Mahabalipuram Road 14 serve Kannagi Nagar's 80,000-plus residents that conforms to or exceeds the standards of

India's national health policy. Goals for the facility could include maintaining around-the- clock physician and nursing staff, an essential drug formulary, a generator, a diagnostic laboratory, a dedicated surgery suite, clinic space, and electronic records.

In an effort to bring healthcare to the people of Kannagi Nagar (not the other way around) before this ambitious project could be completed, a simplified mobile health vehicle could establish a presence in Kannagi Nagar, even if on a part-time, shared basis with other urban underserved areas. Having the vehicle reliably come to the people of

Kannagi Nagar is intended to foster trust in the government-backed system, and accustom the population to expect medical services that will be regularly provided to them rather than withheld or neglected. Some goals for the vehicle could be to hold clinic hours and perform diagnostics as feasible based upon medical workers and equipment on the truck, maintain samples for transport to regional laboratories when necessary, maintain essential medicines, bring medical workers to the tenements to make house calls on residents identified by community health workers as unable to make the trip to the health vehicle, serve as a link in the healthcare chain between the regional medical center and the local community, and transport residents to regional hospitals when feasible.

Community health workers (CHWs) would also play a key role in this patient- centered, point-horizontal approach to providing healthcare in Kannagi Nagar. Faced with a lack of trust in and access to state medical facilities, along with the inability to pay for private healthcare, many residents of Kannagi Nagar turn to traditional healers. The training of traditional AYUSH healers (practitioners of Ayurveda, Unani, and Siddha) overlaps with evidence-based medicine enough that by Indian law, Ayush healers can Running head: Along the Old Mahabalipuram Road 15 practice medicine under some restrictions and with supervision. Other traditional healers have much less formal training. Ayush healers who invest their confidence in this point- horizontal program of evidence-based medicine could be useful in the Kannagi Nagar community, especially if they are already being consulted by the local population, to serve as salaried physician extenders (who follow established protocols) and as a link between tradition and the governmental health service. Female residents of Kannagi

Nagar could also be trained to serve as paid direct observers of therapies, caring visitors to encourage adherence to therapies, data collection agents, and primary links between the local and medical communities. Just as medical anthropologist Salmaan Keshavjee and his colleagues found that crowded prisons (and later, hospitals) in Tomsk, Russia, served as epidemiological pumps to release tuberculosis into the surrounding population, the crowded conditions at Kannagi Nagar could likely serve the same epidemiological function. Keshavjee reduced tuberculosis rates by taking a patient-centered biosocial approach to this problem that included providing food supplements, transportation support, and follow-up contact for patients within a vulnerable population who experienced poverty and lacked access to treatment (Keshavjee ,p. 6). These same social supports could be provided by CHWs in Kannagi Nagar, and also for at-risk pregnant women, undernourished children, persons with HIV/AIDS, tuberculosis, and persons with other communicable or chronic diseases.

Little published information is available in academic journals or other government sources on the prevalence of disease, malnutrition, and maternal/infant mortality in the

Kannagi Nagar tenements specifically, although data regarding the total slum population of Chennai is applicable. This is because Kannagi Nagar contains the key sample Running head: Along the Old Mahabalipuram Road 16 characteristics of Chennai's slums that affect health: urban high-density population and contaminated water sources. One 2006 randomized study of people living in Chennai's slums found that 17% of the study population (n=900) had an untreated respiratory infection. (Viswanathan 2010, p.199). In another study, the annual incidence rate of diarrhea in children per 100 child years was 79.9 (Awasthi, 2003, p. 1147). Vector-borne diseases including malaria, dengue fever, and chickungunya result in significant mortality and morbidity for both adults and children. Environmental controls, including widening the Buckingham Canal, addressing drainage issues in the marshes abetting Kannagi

Nagar, eliminating standing water surrounding the tenements, landscaping the area to manage natural water retention and flow, controlled insecticide use within the tenements, and tapping into the treated Chennai water supply would help reduce both waterborne and mosquito-borne disease, and therefore must be a part of the overall point-horizontal plan for the health of Kannagi Nagar.

Paying community workers to collect and remove solid waste from the tenements would also prevent backups in the nearby waterways, reducing flooding, and therefore, reducing the risk of disease. Indian economist and geographer Annapurna Shaw studied some of the environmental effects of the peripheral slum areas surrounding some of

India's fastest-growing cities, including Chennai. Shaw labels these areas "peri-urban" interfaces, and states that they are especially vulnerable to environmental damage due to their proximity to the city, which could be degrading their land and water resources

(Shaw 2005, p.30). Shaw describes an independent, community-oriented initiative taken by women living in a peri-urban community near Chennai to form a solid waste disposal scheme that hires local workers, collects payment from residents, sets up recycling bins Running head: Along the Old Mahabalipuram Road 17 and waste disposal areas, and then presents the working community-made plan to the regional government for handover. If or when the government fails to remove the waste, the community plan begins again.

Community building is an integral part of the point-horizontal plan of action for

Kannagi Nagar, and this will require advocacy. A small advocate's office could be established in one of the tenements, with a paid worker to engage in the many areas of advocacy necessary for the people of Kannagi Nagar to build a working community: advocacy to eliminate stigma, advocacy to hold local and state governments accountable to their policies to provide care and housing to the displaced people living there, advocacy to keep Kannagi Nagar in the forefront of consideration so that it will no longer be forgotten, advocacy to engender trust between residents and their government, advocacy for measures that could help with community building, such as an outdoor movie theater (this is the usual way to see movies in rural India) or a community market to sell goods, advocacy for children to have access to school, and advocacy for residents to seek and gain access to entitlements that have been granted to other residents of Tamil

Nadu, including the option to participate in national insurance programs, free maternal- child benefits, and nutrition supplements. Pheiffer and Nighter claim that "effective global health action means getting political" and that anthropologists are well positioned to navigate the differing cultures between healthcare workers, governments, donor networks, and the communities that are involved (2008, p. 412), to see with an illuminating and impartial eye which measures are most effective for particular groups of people. As such, ethnography would also play a key role in integrating a healthcare system into Kannagi Nagar, and also helping its residents to integrate themselves into Running head: Along the Old Mahabalipuram Road 18 their surrounding city. What do the residents of Kannagi Nagar most value, and what do they most want to see happen there? What do they see as their largest need? What does the prevailing culture in Kannagi Nagar tell us about how we can appropriately and realistically help? Mahatma Gandhi's guidance to, "recall the face of the poorest and the weakest man whom you may have seen and ask yourself if the step you contemplate is going to be of any use to him" (1958, p.65) is worthwhile to contemplate before taking action in Kannagi Nagar.

Time is not unlimited for action, however, because providing healthcare for

India's poorest citizens is becoming an attractive business in India, especially where for- profit microfinance can be integrated into healthcare systems. According to the New York

Times, "entrepreneurs and venture capitalists, under the umbrella of 'doing well by doing good,' have particularly seized on the idea of impact investing, or applying a businesslike approach to what may once have [once] been a charitable enterprise" (Timmons 2012).

These international financiers expect a return, whether in desired results or in profit, which leads to little or no support of state health infrastructure. George Thomas, chief orthopedic surgeon at St. Thomas hospital in Chennai, India, and editor of the Indian

Journal of Medical Ethics, writes that "A government which believes that medical education and healthcare are best provided by the private sector is deliberately starving hospitals of funds" (2008, p.39). Thomas decries the weakening of the public healthcare system in India, and says that little will change until India's poor see healthcare as a fundamental right. Others call for more research into ways to demonstrate quality of care in order to improve the outlook for the public health sector in Tamil Nadu, and suggest Running head: Along the Old Mahabalipuram Road 19 finding ways to involve the poor in managing their own healthcare to build trust in existing systems (Peters and Muraleedharan, p.2133-2134).

At the heart of the issue is providing health care to an impoverished and marginalized population that cannot be held responsible for providing care unto itself.

This situation, Paul Farmer writes of Haiti in a like fashion, is "crying out for measures to improve the quality of care, not the quality of patients" (1997, p. 353). Globalization has affected India in a troubling manner, in effect, resulting in two societies or two Indias: one of 800 million people living in the margins and another 400 million people experiencing rapid socioeconomic growth and cultural change. How the country handles this exponential growth, as well as how it provides healthcare for its most vulnerable citizens, including those living in the slums along the Old Mahabalipuram Road, will eventually tell much about how the nation of India defines its twenty-first century values and culture.

Running head: Along the Old Mahabalipuram Road 20

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