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Dev S, Duval J, Galivanche A, Shitole T, Sawant K, Shitole S, Patil-Deshmukh A, Lincoln A, Subbaraman R, Weinstein L. Spatializing stigma-power: Mental health impacts of spatial stigma in a legally-excluded settlement in Mumbai, India. PLOS Glob Public Health 2023; 3:e0001026. [PMID: 37471352 PMCID: PMC10358916 DOI: 10.1371/journal.pgph.0001026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 06/08/2023] [Indexed: 07/22/2023]
Abstract
In disadvantaged neighborhoods such as informal settlements (or "slums" in the Indian context), infrastructural deficits and social conditions have been associated with residents' poor mental health. Within social determinants of health framework, spatial stigma, or negative portrayal and stereotyping of particular neighborhoods, has been identified as a contributor to health deficits, but remains under-examined in public health research and may adversely impact the mental health of slum residents through pathways including disinvestment in infrastructure, internalization, weakened community relations, and discrimination. Based on analyses of individual interviews (n = 40) and focus groups (n = 6) in Kaula Bandar (KB), an informal settlement in Mumbai with a previously described high rate of probable common mental disorders (CMD), this study investigates the association between spatial stigma and mental health. The findings suggest that KB's high rate of CMDs stems, in part, from residents' internalization of spatial stigma, which negatively impacts their self-perceptions and community relations. Employing the concept of stigma-power, this study also reveals that spatial stigma in KB is produced through willful government neglect and disinvestment, including the denial of basic services (e.g., water and sanitation infrastructure, solid waste removal). These findings expand the scope of stigma-power from an individual-level to a community-level process by revealing its enactment through the actions (and inactions) of bureaucratic agencies. This study provides empirical evidence for the mental health impacts of spatial stigma and contributes to understanding a key symbolic pathway by which living in a disadvantaged neighborhood may adversely affect health.
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Affiliation(s)
- Saloni Dev
- Department of Health Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, MA, United States of America
- Institute for Health Equity and Social Justice Research, Northeastern University, Boston, MA, United States of America
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States of America
| | - Jasper Duval
- Department of Sociology and Anthropology, College of Social Sciences and Humanities, Northeastern University, Boston, MA, United States of America
| | - Amith Galivanche
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States of America
| | - Tejal Shitole
- PUKAR (Partners of Urban Knowledge, Action and Research), Mumbai, MH, India
| | - Kiran Sawant
- PUKAR (Partners of Urban Knowledge, Action and Research), Mumbai, MH, India
| | - Shrutika Shitole
- PUKAR (Partners of Urban Knowledge, Action and Research), Mumbai, MH, India
| | | | - Alisa Lincoln
- Institute for Health Equity and Social Justice Research, Northeastern University, Boston, MA, United States of America
| | - Ramnath Subbaraman
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States of America
- PUKAR (Partners of Urban Knowledge, Action and Research), Mumbai, MH, India
- Division of Geographic Medicine and Infectious Diseases, Boston, MA, United States of America
| | - Liza Weinstein
- Department of Sociology and Anthropology, College of Social Sciences and Humanities, Northeastern University, Boston, MA, United States of America
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Lubeck-Schricker M, Patil-Deshmukh A, Murthy SL, Chaubey MD, Boomkar B, Shaikh N, Shitole T, Eliasziw M, Subbaraman R. Divided infrastructure: legal exclusion and water inequality in an urban slum in Mumbai, India. Environ Urban 2023; 35:178-198. [PMID: 37275771 PMCID: PMC10237587 DOI: 10.1177/09562478221121737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Inadequate water access is central to the experience of urban inequality across low- and middle-income countries and leads to adverse health and social outcomes. Previous literature on water inequality in Mumbai, India's second largest city, offers diverse explanations for water disparities between and within slums.(1) This study provides new insights on water disparities in Mumbai's slums by evaluating the influence of legal status on water access. We analyzed data from 593 households in Mandala, a slum with legally recognized (notified) and unrecognized (non-notified) neighborhoods. Relative to households in a notified neighborhood, households in a non-notified neighborhood suffered disadvantages in water infrastructure, accessibility, reliability, and spending. Non-notified households used significantly fewer liters per capita per day of water, even after controlling for religion and socioeconomic status. Our findings suggest that legal exclusion may be a central driver of water inequality. Extending legal recognition to excluded slum settlements, neighborhoods, and households could be a powerful intervention for reducing urban water inequality.
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Affiliation(s)
- Maya Lubeck-Schricker
- Department of Public Health and Community Medicine at the Tufts University School of Medicine, Boston, USA
| | | | | | | | | | | | | | - Misha Eliasziw
- Department of Public Health and Community Medicine at the Tufts University School of Medicine
| | - Ramnath Subbaraman
- Department of Public Health and Community Medicine and Associate Director of the Tufts Center for Global Public Health at the Tufts University School of Medicine. He is also an Attending Physician in the Division of Geographic Medicine and Infectious Diseases at Tufts Medical Center, Boston, USA. He is also a research advisor for PUKAR
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Subbaraman R, Nolan L, Shitole T, Sawant K, Shitole S, Sood K, Nanarkar M, Ghannam J, Betancourt TS, Bloom DE, Patil-Deshmukh A. The psychological toll of slum living in Mumbai, India: a mixed methods study. Soc Sci Med 2014; 119:155-69. [PMID: 25189736 PMCID: PMC4252879 DOI: 10.1016/j.socscimed.2014.08.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 08/16/2014] [Accepted: 08/18/2014] [Indexed: 11/21/2022]
Abstract
In India, "non-notified" slums are not officially recognized by city governments; they suffer from insecure tenure and poorer access to basic services than "notified" (government-recognized) slums. We conducted a study in a non-notified slum of about 12,000 people in Mumbai to determine the prevalence of individuals at high risk for having a common mental disorder (i.e., depression and anxiety), to ascertain the impact of mental health on the burden of functional impairment, and to assess the influence of the slum environment on mental health. We gathered qualitative data (six focus group discussions and 40 individual interviews in July-November 2011), with purposively sampled participants, and quantitative data (521 structured surveys in February 2012), with respondents selected using community-level random sampling. For the surveys, we administered the General Health Questionnaire-12 (GHQ) to screen for common mental disorders (CMDs), the WHO Disability Assessment Schedule 2.0 (WHO DAS) to screen for functional impairment, and a slum adversity questionnaire, which we used to create a composite Slum Adversity Index (SAI) score. Twenty-three percent of individuals have a GHQ score≥5, suggesting they are at high risk for having a CMD. Psychological distress is a major contributor to the slum's overall burden of functional impairment. In a multivariable logistic regression model, household income, poverty-related factors, and the SAI score all have strong independent associations with CMD risk. The qualitative findings suggest that non-notified status plays a central role in creating psychological distress-by creating and exacerbating deprivations that serve as sources of stress, by placing slum residents in an inherently antagonistic relationship with the government through the criminalization of basic needs, and by shaping a community identity built on a feeling of social exclusion from the rest of the city.
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Affiliation(s)
- Ramnath Subbaraman
- Partners for Urban Knowledge, Action, and Research (PUKAR), Mumbai, Maharashtra, India; Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA.
| | - Laura Nolan
- Office of Population Research, Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, NJ, USA
| | - Tejal Shitole
- Partners for Urban Knowledge, Action, and Research (PUKAR), Mumbai, Maharashtra, India
| | - Kiran Sawant
- Partners for Urban Knowledge, Action, and Research (PUKAR), Mumbai, Maharashtra, India
| | - Shrutika Shitole
- Partners for Urban Knowledge, Action, and Research (PUKAR), Mumbai, Maharashtra, India
| | - Kunal Sood
- University of California at San Francisco Global Health Sciences, San Francisco, CA, USA
| | - Mahesh Nanarkar
- Partners for Urban Knowledge, Action, and Research (PUKAR), Mumbai, Maharashtra, India
| | - Jess Ghannam
- University of California at San Francisco Global Health Sciences, San Francisco, CA, USA; Department of Psychiatry, University of California at San Francisco, San Francisco, CA, USA
| | - Theresa S Betancourt
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - David E Bloom
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - Anita Patil-Deshmukh
- Partners for Urban Knowledge, Action, and Research (PUKAR), Mumbai, Maharashtra, India
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Subbaraman R, Shitole S, Shitole T, Sawant K, O'Brien J, Bloom DE, Patil-Deshmukh A. The social ecology of water in a Mumbai slum: failures in water quality, quantity, and reliability. BMC Public Health 2013; 13:173. [PMID: 23442300 PMCID: PMC3599692 DOI: 10.1186/1471-2458-13-173] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 02/13/2013] [Indexed: 12/04/2022] Open
Abstract
Background Urban slums in developing countries that are not recognized by the government often lack legal access to municipal water supplies. This results in the creation of insecure “informal” water distribution systems (i.e., community-run or private systems outside of the government’s purview) that may increase water-borne disease risk. We evaluate an informal water distribution system in a slum in Mumbai, India using commonly accepted health and social equity indicators. We also identify predictors of bacterial contamination of drinking water using logistic regression analysis. Methods Data were collected through two studies: the 2008 Baseline Needs Assessment survey of 959 households and the 2011 Seasonal Water Assessment, in which 229 samples were collected for water quality testing over three seasons. Water samples were collected in each season from the following points along the distribution system: motors that directly tap the municipal supply (i.e., “point-of-source” water), hoses going to slum lanes, and storage and drinking water containers from 21 households. Results Depending on season, households spend an average of 52 to 206 times more than the standard municipal charge of Indian rupees 2.25 (US dollars 0.04) per 1000 liters for water, and, in some seasons, 95% use less than the WHO-recommended minimum of 50 liters per capita per day. During the monsoon season, 50% of point-of-source water samples were contaminated. Despite a lack of point-of-source water contamination in other seasons, stored drinking water was contaminated in all seasons, with rates as high as 43% for E. coli and 76% for coliform bacteria. In the multivariate logistic regression analysis, monsoon and summer seasons were associated with significantly increased odds of drinking water contamination. Conclusions Our findings reveal severe deficiencies in water-related health and social equity indicators. All bacterial contamination of drinking water occurred due to post-source contamination during storage in the household, except during the monsoon season, when there was some point-of-source water contamination. This suggests that safe storage and household water treatment interventions may improve water quality in slums. Problems of exorbitant expense, inadequate quantity, and poor point-of-source quality can only be remedied by providing unrecognized slums with equitable access to municipal water supplies.
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Affiliation(s)
- Ramnath Subbaraman
- Partners for Urban Knowledge, Action, and Research, Mumbai, Maharashtra, India.
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Subbaraman R, O’Brien J, Shitole T, Shitole S, Sawant K, Bloom DE, Patil-Deshmukh A. Off the map: the health and social implications of being a non-notified slum in India. Environ Urban 2012; 24:643-663. [PMID: 23400338 PMCID: PMC3565225 DOI: 10.1177/0956247812456356] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Approximately half of all slums in India are not recognized by the government. Lack of government recognition, also referred to as "non-notified status" in the Indian context, may create entrenched barriers to legal rights and basic services such as water, sanitation, and security of tenure. In this paper, we explore the relationship between non-notified status and health outcomes in Kaula Bandar (KB), a slum in Mumbai, India. We illuminate this relationship using the findings of a four-year series of studies in the community. By comparing KB's statistics to those from other Mumbai slums captured by India's National Family Health Survey-3, we show that KB has relative deficiencies in several health and social outcomes, including those for educational status, child health, and adult nutrition. We then provide an explanatory framework for the role that KB's non-notified status may play in generating poor health outcomes by discussing the health consequences of the absence of basic services and the criminalization of activities required to fulfill fundamental needs such as water access, toileting, and shelter. We argue that the policy vacuum surrounding non-notified slums like KB results in governance failures that lead to poor health outcomes. Our findings highlight the need for cities in India and other developing countries to establish and fulfill minimum humanitarian standards in non-notified slums for the provision of basic services such as water, sanitation, solid waste removal, electricity, and education.
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Affiliation(s)
- Ramnath Subbaraman
- Fogarty International Clinical Research Fellow at Partners for Urban Knowledge, Action, and Research (PUKAR)
| | - Jennifer O’Brien
- Research Consultant at the Harvard School of Public Health (HSPH)
| | | | | | | | - David E. Bloom
- Clarence James Gamble Professor of Economics and Demography at HSPH
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de Snyder VNS, Friel S, Fotso JC, Khadr Z, Meresman S, Monge P, Patil-Deshmukh A. Social conditions and urban health inequities: realities, challenges and opportunities to transform the urban landscape through research and action. J Urban Health 2011; 88:1183-93. [PMID: 21850555 PMCID: PMC3232417 DOI: 10.1007/s11524-011-9609-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The process of urbanization entails social improvements with the consequential better quality-of-life for urban residents. However, in many low-income and some middle-income countries, urbanization conveys inequality and exclusion, creating cities and dwellings characterized by poverty, overcrowded conditions, poor housing, severe pollution, and absence of basic services such as water and sanitation. Slums in large cities often have an absence of schools, transportation, health centers, recreational facilities, and other such amenities. Additionally, the persistence of certain conditions, such as poverty, ethnic heterogeneity, and high population turnover, contributes to a lowered ability of individuals and communities to control crime, vandalism, and violence. The social vulnerability in health is not a "natural" or predefined condition but occurs because of the unequal social context that surrounds the daily life of the disadvantaged, and often, socially excluded groups. Social exclusion of individuals and groups is a major threat to development, whether to the community social cohesion and economic prosperity or to the individual self-realization through lack of recognition and acceptance, powerlessness, economic vulnerability, ill health, diminished life experiences, and limited life prospects. In contrast, social inclusion is seen to be vital to the material, psychosocial, and political aspects of empowerment that underpin social well-being and equitable health. Successful experiences of cooperation and networking between slum-based organizations, grassroots groups, local and international NGOs, and city government are important mechanisms that can be replicated in urban settings of different low- and middle-income countries. With increasing urbanization, it is imperative to design health programs for the urban poor that take full advantage of the social resources and resourcefulness of their own communities.
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Affiliation(s)
- V Nelly Salgado de Snyder
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca Morelos, Mexico.
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