Male, mid-thirties, native of Uttarakhand. Upper left arm disfigured due to incorrect vaccination received in childhood. No alcohol or narcotic intake. Working in Delhi since mid-1990s: first as a cycle-rickshaw driver, then construction labour, and finally, since he is growing weaker due to untreated tuberculosis (TB), as a domestic help. Picked up at approximately 8:00pm in a park in Roshan Pura, Old Delhi.

Male, late-thirties, native of Bihar. No visible distinguishing marks. No alcohol or narcotic intake. Working in Delhi since late-1980s as a sewer cleaner. Picked up at approximately 8:15pm as he walked from Old Delhi to Karol Bagh.

The men described above were two homeless men, or “vagabonds” in the Delhi Police’s terminology, whom I encountered on a late Friday night in the Casualty (Emergency Room) of a large government hospital in Delhi. I was there out of curiosity to see what happens during a regular night shift in the Casualty ward of a government hospital. They were part of a group of approximately fifteen men rounded up by the police, as Delhi streets were being swept clean of these vagabonds in an effort to reduce security threats ahead of Republic Day.

I had arrived shortly after the night shift had started. I didn’t have a set agenda, and had arrived with a vague purpose of trying to understand who exactly availed the health services provided at a government hospital, of observing the quality of care, and contextualizing the infrastructural, human resource, and budgetary constraints one hears of in such hospitals.

The Casualty ward was a hub of activity at that hour. Patients ranged from a young man with a rat bite, to a group of teenagers who had got into a street fight; from a young girl with a deep knife wound on her arm, inflicted by her raging adopted brother, to a small baby who was dead on arrival. To take care of all of these patients, there were two resident doctors, two interns, three nurses and a couple of ward boys. A policeman was also present to facilitate with the medico-legal cases (MLC), such as the group of vagabonds and the girl hurt by her brother.

A feisty young resident doctor was in charge, and was mostly busy with the vast amount of paperwork involved for each MLC.  However, to the extent that she could, she also took time to oversee how the interns were examining the patients, asking the interns questions about symptoms and mentoring them through the procedures. She had a great bedside manner: kind and empathetic to all patients she examined, but completely assertive with the rougher patients when she needed to show who was in charge. Through it all, she kept up a friendly banter with her fellow doctors.

As the night wore on, the commitment and leadership from this handful of doctors became apparent. However, there was a clear lack of human resources and it was not enough to deal with other systemic issues that led to the ill health of the homeless and poor migrants in the city. As the migrant from Uttarakhand recounted his tale, he mentioned that he was suffering from TB but had been unable to complete his treatment. Upon hearing this, the accompanying policeman’s expression visibly changed from a “been-there, heard-it-all-before” look, to one that was partly sheepish and partly showed concern. To be denied from taking a full 8-month treatment for TB just because one doesn’t have a “witness” or a caretaker to help deal with the side-effects of the medicine, was news not only to me, but also to the policeman. The police were just following through on orders from above and he tried to reassure me that all the men would be given a comfortable place to stay with a warm blanket. However, there is no way to determine the veracity of that statement or the true nature of their treatment in whatever facility they would have been taken to from the hospital.

As Delhi’s population multiplies and puts pressure on its resources, the need for streamlining and strengthening social protection and welfare schemes for the most vulnerable grows more acute. My experience at the Casualty ward highlighted for me the need to improve on three key aspects: a) a separate administrative wing in Casualty for MLCs; b) shelters for the homeless, and c) access to better health services for poor and mobile populations.

Concerning the first, it was apparent that the Casualty doctors were making the best of the facilities and staff at hand to provide medical care. The doctors shared that certain medicines allotted to the ward did not reach in them in the required numbers and, despite their complaints, no action had ever been taken. More than anything, however, the sheer amount of time spent by the resident doctors in filling out the paperwork associated with MLCs was staggering. One policeman to assist in this process was not enough, and resulted in several patients requiring critical care having to wait for the paperwork to finish. To ease the pressures on the resident doctors, it could be useful to have a separate team of junior doctors or administrative staff that take care of MLCs specifically.

Second, the development and maintenance of night shelters around the city is one of the mandates of the Delhi Urban Shelter Improvement Board (DUSIB). According to DUISB’s web site, at present there are 231 night shelters of various kinds in Delhi (see Table 1 below). There are no concrete figures for number of homeless people in Delhi (it ranges anywhere from 55,000 to 100,000 as a lower estimate) and the High Court has recently reprimanded and asked the DUISB to submit its long- and short-term policies for the homeless in March. If the DUISB puts more energy into providing an adequate number of shelters, perhaps the the susceptibility of these vagabonds to be out in the streets posing a threat could reduce.

Table 1: Night Shelters in Delhi

Type of Night Shelter	Number
Permanent	84
Porta Cabin	98
Tent	22
Voluntary	27
Total	231

Source: DSUIB (2014). http://delhishelterboard.in/main/?page_id=3346

Finally, schemes such as the Rashtriya Swasthya Beema Yojana (RBSY), or the National Health Insurance Programme, which target Below Poverty Line (BPL) households across the country, need to take into account that individuals and families on the move may not always have the required documentary proofs of identity and residence to avail of such basic entitlements. As the examples cited above show, BPL migrants are more vulnerable to occupational health hazards, poor living conditions, and poor access to quality medical services. Thus, it becomes imperative to reflect upon how to include such populations while drafting social protection policies and programmes. The RSBY provides Rs 30,000 annual insurance coverage per BPL household. Provided with smartcards, beneficiaries can avail of cashless treatment upon presentation of the cards at public and private hospitals. However, several studies show that this innovation has yet to take off on the ground and that utilisation rates among the enrolled are actually quite low (see here, here, and here).

There are a number of organisations around the country, such as the Aajeevika Bureau, which have opened resource centres for migrants. These centres provide information on skill development, employment, health and housing services, as well as on legal aspects related to their rights and entitlements. At present, health services for migrants at these centres are not prioritised. Establishing more resource centres along these lines, with a greater focus on health, would go a long way in minimising “security threats” posed by the vagabonds I encountered that night.