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How Surat became India’s public health leader — and stayed that way
SURAT, India — “I don’t have to go to the gym,” says Urmil Kumar Vyas with an impish smile. “Don’t you think climbing 400 steps is enough exercise for a day?”
Vyas and I are wending our way toward a high-rise building in one of the wealthier zones of Surat, a city of 5 million in western India about five hours north of Mumbai. Vyas is a primary health worker in the Surat Municipal Corporation’s Vector Borne Diseases Control Department. He has spent 21 years on the job, and has seen his share of sickness and death. But his energy and sense of humor remain intact.
Vyas joined the city workforce in 1994, the year Surat exploded onto the front pages of newspapers worldwide in the aftermath of a virulent plague. More than 50 people died. Hundreds of thousands more, including migrant workers, fled the city out of fear; businesses across the city shut down.
The spread of the disease was soon controlled. But the plague raised serious concerns about the city’s public health infrastructure, and the capacity of the local government to manage the city.
How Surat used the 1994 plague as a catalyst for improving local administration is a well-known story in India. Two government officials, S. R. Rao and S. Jagadeesan, who served as Surat’s municipal commissioners in quick succession in the mid- and late-1990s, overhauled trash collection and street cleaning, enforced hygiene standards in food establishments and upgraded slums with paved streets and toilets. These and other changes turned Surat from a filthy, flood-prone, disease-ridden city to one of the cleanest in the country today. Despite rapid population growth, cases of mosquito-borne parasitic diseases such as filariasis and malaria are steadily declining.
What is less known is how Surat sustains the initiatives. And that, in the wake of the recent ebola outbreak in West Africa, is an instructive story for city leaders across the developing world. As rapid urbanization strains fragile city health systems, knowing what to do to stop an epidemic is not enough. Constant vigilance and execution is everything.
Following Vyas on his daily rounds offers valuable insights into Surat’s successful strategies. Every morning, the 43-year-old health worker sets out on his motorcycle, like other mosquito warriors of this city on the banks of the river Tapti. For those engaged in mosquito and larvae surveillance, the drill is always the same — ring the doorbell, check if there is someone at home with fever, look for uncovered pots, containers, vases, air-coolers — anywhere standing water is likely to create a fertile mosquito breeding site.
As we enter the high rise, we take the stairs. Vyas visits about 150 homes a day; it takes too long to use the elevator, he says. In his black satchel, Vyas carries disposable syringes and a box full of rapid diagnostic kits. Anyone complaining of fever is tested on the spot for malaria and get a preliminary diagnosis within ten minutes. If they test positive, they are immediately given anti-malarial medicines. This rapid process is known as “radical treatment.” The blood samples are tested once again in the laboratory and positive cases are meticulously followed up to ensure patients stick to the treatment plan.
Malaria is not unique to Surat, of course, nor is disease surveillance. But as Vyas puts it: “Most other municipal corporations start doing door-to-door disease surveillance only when there is an outbreak. We do it round the year. There is strict monitoring.” According to the 2014 annual report of the city’s Vector Borne Diseases Control Department, inspectors tested more than 2.3 million potential breeding spots last year.
All the hard work is paying off. The block of flats we visit is in a neighborhood once infamous as a malaria hotspot. Now, Vyas says, the cases are down by almost 70 percent during the peak malaria season between June and October. Vyas’ colleagues do the same work every day in the poor neighborhoods surrounding the area. Infectious diseases know no class barriers, and if malaria breaks out in one neighborhood it can easily spread to others.
Emphasis on prevention
Vyas plays one small but important role in Surat’s public health infrastructure, which is an unusually robust one for Indian cities. And it is growing.
Unlike many Indian cities, where municipal corporations or local bodies hardly play a role in health care, the Surat Municipal Corporation maintains a fairly extensive network of 41 urban health centers, two major public hospitals and a number of maternity homes. The Corporation also runs mobile medical clinics, and established a medical college and a teaching hospital in 2000. Surat also has more than 500 private hospitals and more than 1,300 private dispensaries where people can buy medicines.
While Surat’s successes are notable, its challenges are also mounting. By one measure, Surat is the world’s fourth-fastest growing city. A rapid influx of migrants seeking work in the signature industries here — textiles and diamond polishing — is putting new strains on the health system. About 40 percent of the city’s residents live in slums. While some diseases have declined, they can easily come raging back if health authorities let down their guard.
Dr. Arpita Patel, medical officer of Athwa (Panas) Urban Health Centre, says Surat is well positioned for the challenge. “We do active and passive surveillance,” Patel says. “We not only have the door-to-door teams, we also offer instant diagnosis for those who walk into this place. Teams of health workers fan out to slums and construction sites. There is a lot of word-of-mouth publicity along with posters and banners.”
Patel says Surat has been successful in reinventing itself because there was political will and resources. Since Rao’s time, Surat has had a run of effective municipal leaders, an active business community and a citizenry that is proud of their city’s status as one of India’s best-managed places. Unlike most local governments in India, the Surat Municipal Corporation, or SMC, is well-staffed and not cash-strapped. Property tax collections are strong, as property owners see the benefits of paying their taxes promptly. Corporation employees are permanent, not temporary, and salaries are paid on time.
What lessons does Surat offer for urban public health policy makers at a time when the fear of pandemics is very real?
Dr. Hemant Desai, the city’s deputy commissioner for health and hospitals, says the key is being proactive about disease — not reactive, as Surat was during the plague outbreak.
“Our emphasis is on prevention,” Desai says. “In 1994, I was a medical officer in the SMC. Then came the plague. Commissioner S. L. Rao took over in 1995 and initiated radical changes. He himself took eight to 12 rounds of the city inspecting if everything was in place. The SMC under him also mapped the filth-spots. Dust bins were installed. The solid waste management system was revamped. There was a timetable for garbage collection and municipal sweepers were each given a beat. Above all, there was supervision and stern action against those who flouted rules. Those who littered were heavily penalized.”
Surat’s prevention approach means employing a small army of people like Urmil Kumar Vyas to do the everyday work of checking on people, administering medicines and collecting data that can help health officials see outbreaks before they become evident in hospitals.
“Without manpower, nothing would have been achieved,” says Keshav Vaishnav, head of the city’s Vector Borne Diseases Control Department. “Surat has 489 surveillance workers. Once every fortnight, they visit every home in the city checking for not only malaria, but dengue, chikungunya, filariasis. Most other corporations lag in surveillance, data, human resources.”
According to Vaishnav, a key element to Surat’s success is close coordination with private medical practitioners, hospitals and laboratories. In most Indian cities, private medical practitioners and institutions are very important service providers and their effective participation in the disease surveillance system is critical for good data.
“We have a good rapport with the municipal corporation,” says Dr. Jayant Shah, a local family physician. “It is a give-and-take relationship. We provide them with data. Cases of specific diseases are notified to the corporation. And in turn, the corporation also keeps us in the loop about disease trends. We have regular meetings with the Corporation’s health department. We get to know about new treatment and protocols.”
The partnership of various associations of doctors and pharmacists with the city’s health department was formally established under the Urban Malaria Project, which ran from 1997 to 2000 with support from the British Department for International Development.
“What you really need is the coming together of a champion, state support and a demanding public,” says G. K. Bhat, chairman of Taru Leading Edge, a consultancy. Taru Leading Edge does work on disaster reduction and response, water, sanitation and hygiene, and partnered with the Rockefeller Foundation to make Surat part of its Asian Cities Climate Change Resilience Network. Surat is also part of Rockefeller’s 100 Resilient Cities initiative. (Disclosure: Citiscope receives funding from the Rockefeller Foundation.)
“Diseases are the net effects of poor maintenance and bad urban services,” Bhat says. “In Surat, the disease surveillance system has been ramped up. Roads have been widened. The drainage system was fixed. Residents of Surat feel a sense of pride in their city. And you can see the results. Filariasis has disappeared. Malaria is down because of intense focus on mosquito breeding control. Water quality has improved because of monitoring. Even after Rao left, Surat got the best administrators as municipal commissioners.”
Dr. Vikas Desai is old enough to remember when Surat was a small fraction of its current size and has lived through most of its modern-day health crises.
“I grew up in a Surat which had open drains,” she recalls. “In the late ‘50s, Surat got underground drainage. A small unit for filariasis control was set up within the municipal corporation. In 1985, Surat was hit by one of the worst bouts of malaria. The disease persisted in the late eighties and early nineties. Then came the plague in 1994. I was then with the public health department of the local medical college. Each night, I used to get phone calls from panic-stricken residents of the walled city. Doctors started leaving.”
Now, Desai is the Technical Director of the Urban Health and Climate Resilience Center. The center was launched in March 2013 as the latest health-related climate change project by ACCCRN — and the first of its kind in Asia. The center conducts research on how climate change is impacting health and patterns of disease — for example, dengue fever used to be a seasonal phenomenon in Surat and many other tropical cities but now is becoming less predictable. The center also plays an advocacy role with policy makers and does training and capacity-building work locally. The Center is an initiative of the Surat Climate Change Trust, an organization that brings together business leaders, policymakers and scientists, with the Surat Municipal Corporation as the main stakeholder.
Like others, Vikas Desai pays fulsome tribute to Surat’s turnaround man, the legendary municipal commissioner Rao. The micro-planning and systems that he put in place has created the public health infrastructure we see today. How has it been sustained? “All Rao’s successors feel compelled to live up to his high standards,” she says with a big smile. “The public is more aware now.”
Paradoxically, Desai says, flooding that ravaged Surat in 2006 gave a further boost to the city’s disease surveillance system. Surat used the crisis to improve the system. “In 2013, floods struck Surat once again,” she says. “But because of the surveillance system, we knew when leptospirosis broke out in the walled city. After the 2006 floods, we started working on disease maps of vulnerable places. As a result, the death rate from leptospirosis in 2013 was half of what it was in 2006.”
Today, Surat is not resting on its laurels. Now, with the UHCRC in the city, it is taking the lead in studying the relationship between climate variability and human health in urban settings. One key focus area is heat stress. As heatwaves continue to sear India, and the death toll from the latest one crosses 1,800, it is easy to see how Surat will inform contemporary urban health debates in times to come.
I asked SMC’s Hemant Desai if one can summarize Surat’s recipe for success in just a few words. Pat comes the answer. “Political will, funds and micro-planning. That is what it took to turn the city around,” he says. “But there is no room for complacency. We have to sustain what we have achieved.”
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