Social Determinants of Urban Indian Women’s Health Status Jyotsana Shukla, Amity University, India KEYWORDS: INDIAN WOMEN, HEALTH, SOCIAL DETERMINANTS, POVERTY, VIOLENCE Indian urban women have come a long way regarding careers and social standing. However, they still remain unaware of their personal well-being and health needs. Often, they ignore their health problems until the problems become unavoidable, chronic or even fatal. The present paper focuses on the determinants of women’s health in urban India, including accessibility of health services, education, gender, class and geographical location, employment, availability of services, social history and culture. The paper also suggests some changes required in policies for improving urban women’s health in India. Background Vandana Mishra, states “I am a natural winner and I had always believed that nothing but the best can happen to me! If only I had thought that even I can be sick. If only I had known that cancer will not spare me despite my looks, my fitness, my job and pay packet. If only I had taken some time out for myself” (Uterine Cancer Stage III patient) (Biswas, 2010). Health status is no longer considered an outcome solely of lifestyle choices. It is now believed that health is also influenced by social, political and economic factors. The sum-total of these factors are called the determinants of health. The current understanding of women’s health has gone beyond singular, individual, biomedical perspectives to include diverse factors such as the family, community, population, psychosocial, and cultural understandings. Social determinants of health also include such factors as education, income, employment, working conditions, environment, health services, and social support (Wuest et. al., 2002). The Universal Declaration of Human Rights(Article 25) states that, “Everyone has the right to a standard of living adequate for the health and well-being of him/herself and his/her family, including food, clothing, housing and medical care and necessary social service. Everyone has the right to education” (What is Foreign Aid, 2010). According to the World Health Organization, “Health is a state of complete physical, mental, and social well-being and not merely the 88 Shukla: INDIAN WOMEN’S HEALTH absence of disease or infirmity”. “Good health requires provision of health care for prevention and treatment of disease and injury, good nutrition and a safe environment. The health of populations has many links with other sectors, such as economic, education, water and sanitation and gender” (Health, 2010). With the world ready to move into the 2nd decade of the 21st century, there is a phenomenal rise in the number of people living in urban areas. The urban population in the continents of Asia and Africa alone is expected to double in a period of 30 years (Earthscan, 2005). With its over a billion population, India has also witnessed the growth of urbanization, similar to other regions in Asia. In fact, India’s urban population is increasing at a faster rate than its total population. It is predicted that 41% (575 million people) of India’s population will be living in cities and towns by 2030, from the present level of 28% (286 million people). There is a close link between economic development and urbanization. Cities in India contribute over 55 % to India’s Gross Domestic Product (GDP) and urbanization has been recognized as an important component of economic growth (UNDP, 2009). Urban Poverty According to estimates of National Planning Commission of India, about 26% of urban population in India is living below the poverty line (Planning Commission, 2007). Using a human development framework, India’s Urban Poverty Report provides many insights into various issues of urban poverty, such as lack of basic services to urban poor, migration, urban economy and livelihoods, micro-finance for the urban poor, access to education and health, and the unorganized sector (Urban Poverty in India, 2007). It is interesting to note that the ratio of urban poverty in some of the larger states is higher than that of rural poverty in some of the smaller states. This is called the phenomenon of ‘Urbanization of Poverty’. Urban poverty correlates with problems of housing, clean water, sanitation, healthcare, access to education and social security. In the continuum of urban poverty, special needs of vulnerable groups like women, children and the aged are paramount. Poor people live in slums which are overcrowded, often environmentally polluted and lack basic civic amenities like clean drinking water, sanitation and health facilities. Most of the slum-dwellers are involved in informal sector activities (such as begging, selling used items in street corners, vending food items), where there is a constant threat of eviction, displacement, confiscation of goods and almost non-existent social security coverage (India: Urban Poverty Report, 2009). Along with other challenges, slum-dwellers also face the constant threat of forced eviction. A forced eviction refers to “the Shukla: INDIAN WOMEN’S HEALTH 89 involuntary removal of persons from their homes or land, directly or indirectly attributable to the state,” with either government assisted or unassisted relocation (Fact Sheet No.25, 1996). Forced evictions are common, and have been documented in several countries including Bangladesh, India, Kenya and Thailand. For example, residents of the Ambedkarnagar slum in Mumbai experienced eviction 45 times during a 10-year period. These evictions included destruction of some or all of the dwellings. The resettlement areas provided lacked basic infrastructure such as water and sanitation (Ompad et al., 2008). Social Determinants of Health (SDH) Social Determinants of Health are the conditions in which people live and work, and these conditions affect their opportunities to lead healthy lives. In March 2005, the World Health Organization set up a Commission on the Social Determinants of Health (WHO, 2005). The commission listed determinants like child development, gender, urban setting, employment, health system, measurement and evidence, globalization, and social exclusion, as central to tackling the prevailing inequalities of health in the world (Labonté & Schrecker, 2007). The final report of the commission concluded that growth alone is not sufficient to achieving health equity, the distribution of health services is equally important. The three important pillars of action according to the report are: 1) improve the conditions of life and the circumstances in which people live and work, 2) address the inequitable distribution of structural drivers—power, money and resources—at the global, national and local levels, and 3) measure the problem, evaluate the actions and address the issue of human resources through which health services can be delivered (Nayar & Kapoor, 2007). On the basis of the recommendations of the CSDH, the 62nd World Health Assembly, requested the Director-General of WHO to make social determinants of health a guiding principle, while taking into consideration the progress on objective indicators for monitoring the social determinants of health. The Assembly also recommended that the Director-General give priority to addressing social determinants of health, support the member states in promoting access to basic health services, provide support to member states in implementing a ‘health-in- all-policies’ approach to tackle inequities in health (Eighth plenary meeting, 2009). It is an accepted fact that basic health-care, family planning and obstetric services are essential for women, yet these facilities remain unavailable to millions of them in the developing world. Moreover, many believe that the health of families and communities are tied to the health of women. The illness or death of a woman has serious and far- 90 Shukla: INDIAN WOMEN’S HEALTH reaching consequences for the health of her children, family and community (The Importance of Women’s Health, 2005). Women’s Health in India In India, gender-based health indicators have shown improvement over time, however, these developments are still far from optimal. In comparison to the European states, the difference in gender- based indicators is enormous. For example, among cause-specific mortality rates, maternal mortality rate in India is 16.6 times, TB among the HIV positive population is 2.8 times, and age-standardized mortality rate from non-communicable diseases is 1.2 times the comparable rates in Europe. Only the incidence of cancer in India is significantly lower than in the EU (WHO, 2009). Indian Urban Women’s Morbidity The health of Indian women is linked to their status in society. The society is patriarchal, and there is a strong preference for sons in India. This bias sometimes results in the mistreatment of daughters. Further, Indian women have low levels of both education and formal labor force participation. Typically, they have little autonomy, living under the control of first their fathers, then their husbands, and finally their sons (Velkoff & Adlakha, 1998). To gain a better perspective on the health status of urban Indian women, it is important that we look at some of the selected diseases from which women frequently suffer, and compare them with the prevalence rates amongst their rural counterparts, and also compare them with men. Diabetes, Asthma & Goiter In cases of diabetes, asthma and goiter, urban women do worse than their rural counterparts. Also, women suffer from goiter more than men, both in rural and urban areas, by about 1.93 and 3.62 times, respectively. Moreover, urban women suffer more from asthma than their male counterparts (Sengupta & Jena, 2009). Cancer Though the incidence of cancer is still low in India compared to that of developed countries, incidence of breast and cervical cancer is becoming increasingly significant. According to the National Sample Survey (NSS, 2004), out of every 1000 women, 33 in urban areas and 39 in rural areas were hospitalized due to cancer. A recent survey done by WHO reveals that every year 132,082 women are diagnosed with cervical cancer and 74,118 die from the disease.