Taking lessons

Infernal cities: Like London in a bygone age, Delhi has turned into the site of nightmares

Smoke and urban congestion in Britain gave rise to theories of pollution to begin with.

The idea of the city as hell is not new. William Blake, writing in 1794, takes a bleak view of London, bound up in bans and charters, where the “Chimney-sweeper’s cry/ Every blackening Church appalls”. The blackening may be physical as well as moral. Very young boys were sent down chimneys belching out coal dust and smoke, often to die early, victims of the new economy that was reordering England. Soot-stained churches watched over their deaths, corrupt and aloof.

The hell fires were to stay for the next two centuries. London and other industrial towns in England would grow accustomed to sulphurous fumes spewed out by factories and coal dust hanging in the air, enclosing the city in a murderous pall. By 1915, when TS Eliot was writing of the “yellow smoke that rubs its muzzle on the window panes”, it had become a melancholy feature of the big city.

The bloated, congested British town was where pollution was invented, writes Peter Thorsheim. The period of intense urban growth in the 18th and 19th centuries seems to have invented urban dystopias as well. The infernal city, where cosmopolitanism and progress turned into overcrowding, squalor and apocalyptic smog, warned that new technologies could transcend environmental limitations but their consequences could not be controlled.

Today, there are new infernal cities on the map: Beijing in China; Lahore in Pakistan; Delhi, Allahabad, Moradabad, Agra, Kanpur and many more in India, all choking in their yellow smoke.

‘Not fit for humans’

Anecdotes about London’s growth are not unlike stories told of Delhi today. In 1749, for instance, an event to celebrate the Treaty of Aix La Chapelle, featuring fireworks and new music by George Frederic Handel, drew so many people that the London Bridge saw a three-hour traffic jam. And sometimes, the smog outside was so thick that busy shops needed candlelight even during the day. Does this similarity go beyond anecdotes, to patterns in the growth of the two cities?

Britain’s population grew from five million in 1700 to around nine million in 1800, with large migrations from the countryside to the city, where industries were burgeoning. Between 1714 and 1840, London’s population swelled from 2,30,000 to nearly two million. In the Victorian period, it leapt to around 6.5 million.

As London grew overcrowded, the city spread, swallowing up the surrounding countryside and turning small towns and villages into dull, undifferentiated suburbs. In the early 1800s, for instance, the astronomer William Herschel had set up his telescope in the town of Slough, where he could look into a night sky without a city haze. By 1937, Slough had become part of an industrial hinterland in the Greater London area, and the poet John Betjeman was appealing, “Come, friendly bombs, and fall on Slough! It isn’t fit for humans now.”

Apart from industry, railway stations came up in London in the early 19th century, with steam engines. In spite of the prominence of industrial smoke, Thorsheim points out, a large part of the haze rose out of consumption by a growing urban population. Smoke came from rapidly multiplying domestic fires, coal gas lamps and steam engines. Besides, until the mid-19th century, the city stewed in the constant fug of open sewers, bubbling with offal and human excrement.

In India, cities would see rapid growth in the 20th century. Post-Independence, economist Amitabh Kundu writes, industrialisation and investment in infrastructure drew people to the urban areas of developed states. Delhi’s population growth was more accelerated than London’s, shooting up from 1.7 million in 1951 to 16.75 million in 2011.

Like Greater London, the Delhi metropolitan region has grown through the annexation of surrounding rural areas. From 1901 to 1991, notes Veronique Dupont, Delhi absorbed 185 villages into its urban limits to become a megacity. Today, the National Capital Region is spread over 1,483 square kilometres, with a population of over 46 million. In 1991, just 685 square kilometres of the city were urbanised compared to 1,114 square kilometres in 2011.

In the 1950s, there was worry about where the swelling population would be housed. A socio-economic survey conducted by the University of Delhi in 1955 estimated that by 1961, the city would face a shortage of 1,50,000 homes, in addition to 50,000 dwellings that were so substandard they would have to be demolished. Almost 70% of the city’s families lived in one room houses, without a bathroom or kitchen. The sewerage systems had not been completed either.

From 1961, Dupont writes, public authorities played a role in urban growth, setting aside large land reserves mainly by purchasing agricultural plots. In satellite townships such as Noida, the administration constructed various grades of housing. But this still left out a majority of the workforce employed in the growing industries. They found rooms in surrounding rural areas, which were then urbanised. Besides, a large number of unauthorised colonies, including luxury housing, rose up on the peripheries. Now, thousands of people commute every day from the edges of this thickening urban mass to the city centre for work.

Like London earlier, the skies above Delhi may be clouded by the vapours of consumption more than industrial production. As Nilanjan Ghosh notes, the transport sector contributed 72% of Delhi’s pollution in 2001 while the industrial sector accounted for 20% and the domestic sector 8%. Particulate matter, the great villain of Delhi’s smog, comes from power stations and industrial processes, but also from fuel combustion, construction, diesel vehicle exhausts, re-suspended road dust and the burning of domestic refuse.

The Great Smog of 1952 engulfed London for days and is believed to have killed 12,000 people.
The Great Smog of 1952 engulfed London for days and is believed to have killed 12,000 people.

‘Fog everywhere’

In spite of Blake’s nightmarish vision, great plumes of coal smoke spreading over London were once looked upon with quiet pride, the sign of progress and prosperity. Perhaps not unlike how industrial skylines in India are celebrated as proof that the pistons of development are still moving.

Until the mid-19th century, writes Thorsheim, coal smoke was even seen as an antidote to miasma, poisonous biological gases believed to cause death and disease. But with the conceptual disappearance of miasma, theories of pollution began to swirl around with smoke. Why this transition? Probably because by the 1850s, the air quality had become unbearable, Thorsheim surmises.

England was getting used to “pea soupers”, a fog that was mostly yellow from sulphur although it could shade into orange, rust and brown. It was so thick you might even swallow it. From the 19th century and well into the 20th, London would see apocalyptic events. In the 1850s, fumes rising from the Thames would create the Great Stink of London and corrosive showers would lead scientists to coin the phrase “acid rain”.

This was also the age that coined the word smog. Sulphurous mists descended upon London in 1873, 1880 and 1892, killing hundreds. In the century that followed, the mists would grow even more deadly, culminating in the Great Smog of 1952, which engulfed the city for days and is believed to have killed 12,000 people. It led to the Clean Air Act of 1956, which finally put out coal fires in English homes. But literature had expressed a sense of foreboding much earlier.

A scene from Bleak House.
A scene from Bleak House.

Already in the early 19th century, travellers approaching London would be filled with a mix of terror and awe. Thomas De Quincey, wandering the streets in a gin-sodden, opium-wreathed haze, would mix with its miserable working poor. By 1853, the promise of the teeming, industrial city was turning, quite literally, to ash.

Charles Dickens’s Bleak House opens with lines that have become an epitaph to the industrial age: “flakes of soot” which mourn the “death of the sun” and “fog everywhere”, snaking down the river and rolling “defiled among the tiers of shipping and the waterside pollutions of a great (and dirty) city”.

The smoke would reach other urban centres, to Coketown of Hard Times, a thinly fictionalised version of Manchester, ruled by ruthless utilitarians. It would fuel industrial unrest in Elizabeth Gaskell’s version of Manchester, the cold town of Milton. In Charles Kingsley’s Water Babies, young chimney sweepers drowned to escape into other worlds.

The smog produced enervated urban populations prone to weaknesses such as alcoholism, fainting, early death, labour strikes. It also conjured up monsters. Jack the Ripper always emerges from the fog, no matter how many historical records assert that he killed on clear nights. And Sherlock Holmes pursues disappearing figures down smokey alleys and dockyards.

New spectres

Pollution turned cities into hell for the mind and hell for the body. Among other effects that were being written about in the late 1800s was the separation of the rich, who could afford to move to breezier climes, from the poor, who rotted in slums and sooty furnaces. Add to that the terrifying prospect of scarcities, of water, shelter and energy. Many tracts began to speak of deserted cities.

These are conversations that haunted Indian cities, especially Delhi, this week. The Capital has long featured among the world’s most polluted cities, and its residents remember a time in the 1980s when dense black automobile fumes would choke commuters.

An intense period of urbanisation in the 1970s appears to have stirred a new consciousness about its environmental hazards. The Air (Prevention and Pollution Control) Act of 1981 and the Environment (Protection) Act of 1986 tried to control automobile and industrial fumes. Mass emission norms for both petrol and diesel vehicles were first articulated in the early 1990s, though they would take some years to implement.

In the public imagination, Delhi seemed to fluctuate between the aspirational “world class” megacity and the polluted inferno, infested with crime and corruption. Over the last decade or so, the first image seemed to dominate public policies. By the early 2000s, the city saw a host of new malls rise up. In 2010, it was the city of the Commonwealth Games, for which flyovers were built, new apartments constructed along the Yamuna and beggars cleared from streets. In 2016, the banks of the Yamuna would be the site of a massive Art of Living festival that is believed to have caused lasting damage to the floodplains.

This week, though, gave rise to new spectres. The city floated in its own particular brew, possibly more curry than pea soup. Vague faces in masks wafted through the fog, like survivors of a nuclear holocaust, like characters in an HG Wells novel. This week, Delhi completed its descent into hell.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.