INDORE, INDIA — In this small commercial city, two worlds sit side by side. One side is the comfortable middle class. The other - tucked into alleyways or barren lots - are slums that look like a scene out of Mad Max: low-roofed tin huts; wild-haired children walking naked.
For centuries, these two worlds have been symbiotic. Slums provide housecleaners, cooks, and drivers for the middle class. The middle class, meanwhile, tolerates the slums as a source of cheap labor.
But this system is buckling under the pressure of India's burgeoning urban population, particularly over issues of health. Urban slums are the fastest-growing sector of India's population, expanding five times faster than rural areas. How the government deals with this problem could have widespread implications, both for the country's ability to attract foreign investors and to convince upwardly mobile citizens that life is safe enough to remain in India.
"When you analyze the urban slums and the statistics that slums will be growing at faster rates than other [areas], this is a serious concern," says Prasan Kumar Hota, secretary of family welfare in the Indian Health Ministry.
Urbanization is a global phenomenon. In wealthier nations, most citizens already live in major urban areas or suburbs. But for poorer countries, the epic migration of villagers to cities is straining clean water supplies, sewer systems, and hospitals. Of the roughly 2 billion people to be added to the world's population over the next 30 years, more than 90 percent will be living in the cities and towns of poor countries, according to The Challenge of Slums, a recent report by the UN agency Habitat.
In India, there is a cruel twist. Decades of rural programs have brought clinics and healthcare to villagers. But now villagers are often leaving behind better healthcare in search of better jobs. In a recent survey in the state of Gujarat, for example, researchers found that 60 percent of surveyed villages had vaccinated their children, compared with 30 percent of slum dwellers.
A small collection of government bureaucrats, private volunteer groups, and feisty community leaders are starting to address the imbalance, one slum at a time. Here in Indore, an innovative pilot program - funded by USAID and run by private healthcare advocacy groups - is helping slum dwellers improve their own health conditions. With limited funding, this program chose 75 of the most vulnerable slums (out of 543), and focused first on education.
"The most important thing is to deal with the sense of resignation that you find among most Indian slums," says Siddharth Agarwal, executive director of Environmental Health Project (EHP), a private aid group in New Delhi leading the Indore project. "These people should be the implementers. We may be wonderful doctors, but we will disappear one day, so if a program is able to train five people in that community, then the effort can be sustained."
Training includes lessons on good nutrition, safer birthing methods, better sanitation, proper disposal of waste products, and proper hygiene, such as washing hands before food preparation. Some slum dwellers are learning how to demand access to drinking water and affordable health clinics.
The irony, says Mr. Hota, is that both politicians and villagers assume that the issue of urban healthcare will just resolve itself. "Somehow we all expect that urban poor, with higher incomes, higher number of doctors and hospitals, should be able to take care of themselves. But that is not true."
In fact, says Mr. Agarwal, 71 percent of the slum dwellers in Indore go to private doctors, "many of whom are not licensed, and all of whom are expensive."
In Professor's Colony here in Indore - a neighborhood of modern concrete homes near the university - a band of women - middle-aged, poor, and barely literate - are educating themselves now on how to prevent health problems.
Every few weeks, they meet with tutors from EHP in an effort to prevent illnesses that can devastate a poor family. During hot afternoons, during times that used to be reserved for gossip, the women share what they learn with other women in the area.
Tara Bai, a 60-year-old who came to Indore 30 years ago, has learned more about childbirth in the last year than in all her life. Before, improper practices in washing babies after birth meant that more than half would die overnight from hypothermia. Before, mothers didn't use a sterilized string to tie the umbilical cord; many children died of infections.
Today, infant mortality in Tara Bai's slum has dropped dramatically.
"We've had 8 to 10 births so far this year, and no deaths," she says. Her hut has become a meeting place of sorts for the 100 families of this slum. "If God gives light to you, you should know how to use that light."
Best of all, Tara Bai says, this education is portable. So if city officials carry out threats to remove this slum, Tara Bai says, "I know how to go to a new slum and organize it; I can do it again."
Across town, in a slum at the city's scruffy edges, Shanta Bai (unrelated to Tara) has also been taking courses in healthcare, and improving the lives of her neighbors. (Bai is a common last name for Indian women here; it means wife in Hindi.) Shanta Bai comes from one of the poorest communities in Hindu society, the caste of ragpickers, who collect and sort trash for recycling. She's illiterate, but acts as a community pillar.
"This slum has been moved three times in 15 years," she says, adding that she was born into an Indore slum 60 years ago. "But there is a support system here. We look out for each other."
She says her training has made her better prepared. "Before the class, I was blind. I would never have realized ... that we could do all this together," she says. "It's opened my eyes."