Legal Exclusion as a Determinant of Health

by Amith Galivanche

Mentor: Ramnath Subbarman, Public Health and Community Medicine, TUMS; funding source: Nathan Gantcher Student Summer Scholars Fund


About one in eight people globally reside in urban slums. Slum health is important in the realm of global public health and the United Nations has developed a definition for “slum” that is fairly comprehensive. It incorporates aspects of slum life that include poor access to safe water, cramped living conditions, insecure housing tenure, and difficulty accessing basic services. However, where this definition falls short is also where most research on slum health falls short—it fails to address the vast disparities that exist between urban slums in terms of legal status.

In India, about 60 percent of people living in slums live in “non-notified” slums, which, in contrast to “notified” slums, are not recognized by local governments as legitimate settlements. For non-notified slums, there exists no pathway to accessing certain basic services through the city such as safe piped water, adequate sanitation, or waste-disposal, and these communities are often additionally plagued by social stigma that feeds into this legal exclusion. Additionally, housing tenure is typically unstable in non-notified slums, which goes hand-in-hand with poorer living structure quality.

It is well-understood and established that water, sanitation, and hygiene (WASH) infrastructure, housing tenure, and housing quality are all directly correlated with health outcomes. Therefore, it is important and relevant to study the effects of legal exclusion, which further complicate the obstacles that all slum residents face in protecting the health of themselves and their communities.

This project aims to understand the disparities between notified and non-notified slums, establish that they exist, and assess whether or not notification can improve these outcomes for slums that are not currently notified. This was done largely through a literature review on the limited amount of literature that currently exists on the impact of legal exclusion and notification on basic services, housing tenure, and health outcomes.

Additionally, an integral part of this project is the gathering of life narratives from individuals residing in a non-notified slum in Mumbai called Kaula Bandar. Currently, interviews are in progress. In order to inform this project so far, interviews with residents of Kaula Bandar from a few years ago were qualitatively coded and their life experiences, especially pertaining to the toll that it takes on their mental health, were analyzed and quotes were pulled to provide an individual perspective.

The literature showed that access to basic services is markedly poorer in non-notified slums in Mumbai compared to notified slums. In another paper, it was shown that, in Aligarh, women in non-notified slums had poorer maternal health outcomes than those living in notified slums. These two studies are just the tip of the iceberg in terms of the disparities that exist.

Next, literature was reviewed to determine whether or not notification could be an effective method of improving poor outcomes. While there is very little literature on legal exclusion and notification as they relate to health, some literature did show a positive correlation between notification and improved access to basic services over a long period of time. For example, it is shown that, when comparing progress in notified slums versus non-notified slums over a period of several years, non-notified slums stayed stagnant while notified slums improved drastically. Additionally, some literature showed that improving land-tenure rights led to improved housing structure quality.

In summary, it is important to consider that global public health solutions may revolve around these policy implications. It is important for duty-bearers to consider that improving health outcomes for marginalized populations may go hand-in-hand with enacting policy reforms to address current systems of legal exclusion.

5 thoughts on “Legal Exclusion as a Determinant of Health

  • October 23, 2020 at 5:12 pm

    This is such an impressive and meaningful project, Amith. I appreciate the context you provide on urban slums and the difference between “notified” and “non-notified” slums. Good luck continuing your work in sharing the experiences of those in Kaula Bandar, and through this, working towards the notification of this slum and others. (This project also reminds me of a journalistic novel called “Behind the Beautiful Forevers” that takes place in a slum in Mumbai and, like your project, uses interviews and the telling of stories to advocate for change).

  • October 23, 2020 at 5:58 pm

    Hi Amith, thank you for sharing this poster. I learned so much more about urban slums, especially in the context of health and healthcare. This is such an important issue, and I am curious to hear and learn more about these personal interviews.

  • October 23, 2020 at 6:00 pm

    Hi Amith, this is a really exciting project, I hope we get to hear about the outcomes of the interviews you are conducting. While reading about the problems you present with legal exclusion in terms of lack of access to basic resources, I was reminded of an article I recently read for a class on Forced Migration. In that article, the author, Lucy Hovil, suggests that self-settled Somali refugees were frequently better off economically than officially registered refugees in camps in Uganda because of the failures of Ugandan refugee policy. Of course, local communities have entirely different dynamics than refugee communities and Uganda is not India, however, I am wondering if there are any benefits to “non-notified” slums in terms of economic opportunities as was the case in the Ugandan camps. The data presented in your poster indicates very broad health disparities, but is there any kind of trade-off in terms of which resources and opportunities are accessible in the different slums? Are residents of “non-notified” slums in these settlements entirely because they have nowhere else to go or was there an initial incentive driving them to live there? Apologies if these questions are uninformed.

  • October 23, 2020 at 7:16 pm

    Amith, I remember attending your presentation and it was wonderful. Your exploration of social and resource exclusion made me think a lot about the concept of ‘citizenship’ and who the state (and actors of the state) ascirbes worth to, and more importantly how that impact health outcomes and living conditions. Your work also reminds me of “Hydraulic City” an ethnographic exploration of Mumbai’s water infrastructure and the precarcity that citizens in different regions experience around access to reliable water. Amazing work, congratulations!

  • October 23, 2020 at 11:34 pm

    Great presentation – in many lists of health determinants, legal exclusion is notably absent as a factor. This really sparks me into thinking what the process of rectifying this process would be, working within the governmental and policy bounds that have been set up in the areas where this is taking effect.

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