Mosquito-borne disease, waste pickers and health equity: a co-produced study in Andhra Pradesh, India

Abstract

Mosquito-borne diseases (MBDs) thrive in the environmental conditions of poverty and disproportionately impact the poor. In India, low coverage of vector control and health care interventions in marginalised groups poses a significant challenge to malaria elimination, and to control of dengue and chikungunya outbreaks. Waste pickers – people of low caste who are informally engaged in the collection of recyclable solid waste – are a historically and systemically oppressed group in India, who live and work in extremely poor conditions. While research on this group is limited, evidence suggests that waste pickers face a plethora of challenges to their health and wellbeing, including potentially elevated vulnerability to MBD, which further perpetuate cycles of poverty. As such, MBD prevention and treatment in waste picking communities is a health equity issue.

This research used a co-production approach to explore different perspectives on MBD in waste picking communities in Andhra Pradesh, India, to understand their impact on this group and inform the co-development of locally adapted strategies for intervention. Three interlinked studies were conducted to (1) understand waste pickers’ perceptions of risk, health-seeking behaviours and contextual factors relating to MBD, using focus group discussions, participatory mapping and Photovoice; (2) identify health systems barriers to reaching waste picking communities with MBD prevention and treatment interventions, using key informant interviews and observations; (3) initiate a co-development process with waste pickers and health systems actors to generate solutions to MBD in waste picking communities, using a multi-stage participatory workshop approach.

Intersecting factors linked to caste/tribal affiliation, informality, urbanicity, poverty, occupation and gender increase waste pickers’ vulnerability to MBD. Lack, or inadequacy of, basic infrastructure and service provision for water, sanitation and waste management in waste picking communities creates ideal environments for mosquito breeding, and there are few avenues for waste pickers to seek accountability from the government to address this. Waste pickers are disconnected from the public health system, overlooked in service delivery at the local level due to a lack of awareness that these small, scattered communities exist, and to discriminatory assumptions about waste pickers. This feeds into the data vacuum around MBDs in waste picking communities, which alongside a hierarchical and unresponsive health system structure, maintains the invisibility of waste pickers as a vulnerable group in the peri-urban space. High opportunity costs and negative experiences of utilising government

health facilities creates a preference for waste pickers to self-treat ‘fevers’ or seek care in the private sector. Bringing waste pickers and health systems actors together in the workshops represented an important step in building relations between these groups, and supported discussion of both community-based responses to MBD (community clean ups, community health champions) and those for which the health system and local government should be held accountable (increasing bed net distribution, drainage improvements, housing upgrades). While power imbalances compromised the productivity of dialogue in the workshops, they highlight the need for institutionalisation of more participatory community engagement approaches.

This research shows that MBD control programmes must be integrated within the move towards more equitable, people-centred health systems to better meet the needs of marginalised groups such as waste pickers. Simultaneously, greater efforts must be made to address upstream social and environmental determinants of health which are fundamentally linked to MBD prevalence in informal spaces, requiring strong multisectoral collaboration and alignment with broader sustainable development goals.