Discuss migration and urbanisation as determinants of health.

Migration and Urbanisation

• The types of migration — internal (rural to urban, rural to rural, urban to urban, urban to rural) and international; permanent, seasonal or circular; and voluntary or forced, the latter including displacement by conflict, disaster or development projects
• Seasonal and circular migration is the dominant Indian pattern — agricultural workers, construction labour and brick kiln workers moving for part of the year and returning
• The push and pull factors — push: poverty, landlessness, unemployment, drought and crop failure, debt, conflict and disaster; pull: employment, higher wages, education, health care and the perception of opportunity
• The health effects on the migrant:
• Loss of entitlement is the most important and least appreciated — ration cards, immunisation records, antenatal registration and scheme eligibility are tied to a place, so a migrant loses access to services they were entitled to at home without gaining them at their destination
• One nation one ration card was introduced precisely to address this portability problem for food entitlements
• Interrupted care — antenatal visits, immunisation schedules, tuberculosis and HIV treatment and chronic disease follow-up are all broken by movement
• Interrupted tuberculosis treatment is a particular concern, since it creates drug resistance, which is a consequence for the whole population and not only for the migrant
• Living and working conditions — overcrowded and insanitary housing at worksites; occupational hazard and injury; lack of safe water and toilets; and exposure to vectors
• Specific health risks — tuberculosis and respiratory infection from crowding; malaria, both acquired and carried between areas of differing endemicity; sexually transmitted infection and HIV, migrants being a recognised bridge population; malnutrition; substance use; injury; and mental health problems from isolation, insecurity and separation from family
• Effects on the family left behind — women left managing households and land alone; children with interrupted schooling; elderly people left without care; but also remittances, which improve nutrition, housing and education — so the effect is genuinely mixed rather than uniformly negative
• Urbanisation in India — a rising urban share, with growth driven by natural increase, migration and the reclassification of rural areas as urban
• The urban health paradox must be explained — urban averages for health indicators are better than rural ones, yet the urban poor frequently have outcomes worse than the rural average
• The reason is that the urban average combines a very well-served affluent population with a very poorly served slum population, so the average conceals both — which is the clearest possible demonstration of why data must be disaggregated
• The health problems of urban slums — overcrowding; inadequate water and sanitation with shared or absent toilets; poor solid waste disposal; air pollution; vector breeding in stored water; tuberculosis; malnutrition alongside rising obesity and diabetes; injuries and road traffic; substance use and violence; and lack of tenure, so that residents may be evicted and are frequently excluded from official schemes for want of an address
• The absence of a recognised address is a health barrier in itself, since entitlements, records and follow-up all depend on one
• The response — the national urban health mission, with urban Primary Health Centres and Health and Wellness Centres, ASHAs for slum populations, and Mahila Arogya Samitis; portability of entitlements; mobile and outreach services with flexible timings suited to working people; worksite health services; slum upgrading, water, sanitation and housing; and registration and tracking systems that follow the person rather than the place
• Urban averages conceal both extremes, combining the very well served with the very badly served in one figure
• The urban poor may do worse than the rural average, which is the clearest argument there is for disaggregating data
• Entitlements are tied to a place, so a migrant loses access at home without gaining it at the destination
• Interrupted tuberculosis treatment creates resistance, which is a consequence for everyone rather than for the migrant alone
• Migrants are a recognised bridge population for HIV, carrying infection between high and low prevalence areas
• Lack of an address is itself a health barrier, since entitlements, records and follow-up all depend on one
• Seasonal and circular movement dominates in India, rather than the permanent relocation the word migration suggests
• Remittances improve nutrition and schooling, so the effect on the family left behind is genuinely mixed
• Reclassification contributes to urban growth, alongside migration and natural increase, and is often forgotten
• Slum residents lack tenure and may be evicted, which excludes them from schemes requiring a permanent address
• Track the person rather than the place, which is the design principle that portability schemes are built on
• Offer services at times working people can attend, since a clinic open only during working hours excludes the urban poor
• Stored water breeds Aedes in slums, which links intermittent water supply directly to dengue transmission