Tracey Koehlmoos: We are human: the homeless in Bangladesh

Tracey KoelhmoosWhen the little woman in red arrived at the dissemination seminar of the Urban Partnerships for Poverty Reduction Programme (UPPR), I was dually impressed by her small size and that she bought her toddler with her. Although my three sons consume most of my time and effort outside of work, I’ve never been to a business meeting where someone brought a child. It was unusual for Bangladesh.

The meeting was chaired by the Ministry of Local Governance who are responsible for the development, management, and delivery of public services in urban areas. The actual purpose of the meeting was a dissemination seminar of a survey conducted by UPPR of the homeless in twenty urban centres, excluding the capital, Dhaka. The audience was primarily mayors from the 25 or more towns where the research had been conducted as well as a sprinkling of the other groups working on homeless issues. I had been invited to present the preliminary findings of my work testing a low cost model of health service delivery, custom-designed to serve the homeless.

After the dissemination of the results, the mysterious woman in red, toddler squirming on her lap started to speak. She had been bought in by one of the groups who is working with the homeless people. Her first words were, “I am homeless.” She then spoke about how she came to live on the streets—job seeking with a husband who then abandoned her and the children. Her story was one of horror, a child beaten to death by police, babies stolen while the mothers slept, the endless hunt for some money and some food. She ended by beseeching the mayors and the partnership to help her, to help people like her. They want jobs, they want a roof over their heads, they want safety for their children. She ended with a long, melodic pleading of “I am human. I am human. We are human.”

Having been reminded that we had more in common then perhaps we would like to think. I choked up a bit. The mayors had been silenced by the end of her talk.

No one had any questions after such a frank call for help. It was my turn to present next and I could not. How could I follow such a plea with my remote discussion of medical records, vaccination rates, and referral usages. My work is one tiny drop in the ocean—health service delivery in three sites (a stadium, a bazaar, and a train station) to about 50 patients per night.  Even if we bring this approach to scale, I know that health services will not lift this woman or people like her out of poverty. It will not create a job for her or put a roof over the heads of her family.

The homeless in Bangladesh generally drift or flood into the cities looking for economic opportunities but lack the education and the connections to fulfill their hopes. For the last three decades the urban population in Bangladesh has grown more than 6% per year. Dhaka alone adds another 300,000-400,000 rural migrants per year.

In 2007 my team did research showing that a lack of proper housing or insecure tenure leads to extortion, high unemployment, escalating violence, poor health and hygiene, as well as sexual abuse, and drug abuse among the homeless. [1] They congregate by the hundreds and in some areas by the thousands in the same main spots around town every night, year after year. Most of the homeless, at least in Dhaka, have been on the streets for more than 3 years (60%) and some for more than 10 years (an additional 20%). Despite high levels of self-reported illness, they do not use medical services. [2]  We proved that the homeless were not a floating population, but long term residents of the city who lacked basic resources and should not be ignored.

It is difficult to remain engaged only as a scientist in the face of such a call for action like that from the lady in the red shalwar kameez with her squirming toddler, another wake up call to the reality of such deprivation. If I share my results with anyone and everyone who has influence and resources, when do I become an advocate? And, when does advocacy become the responsibility of the scientist?

1. Koehlmoos T, Uddin J, Ashraf A, Rashid M (2009) Homeless in Dhaka: Violence, Sexual Harassment and Drug Abuse. J Health Population Nutrition, 27(4):452-61.

2. Uddin J, Koehlmoos T, Ashraf A. (2009) Health Needs and Health Seeking Behaviours of street dwellers in Dhaka city. Health Policy and Planning. 24(5):385-94.

Tracey Koehlmoos is programme head for health and family planning systems at ICDDR,B and adjunct professor at the James P. Grant School of Public Health, BRAC University.