Caste is a major indicator of health outcomes and mandates the need for interventions that change social structures.
The caste system, with its societal stratification and social restrictions, continues to have a major impact on the country. The system, generally identified with Hinduism, is also prevalent among Christians, Sikhs and Muslims.
While some barriers are broken in urban settings, many continue to persist in rural India. While the secular, socialistic and democratic principles enshrined in the constitution demand equality of outcomes, the inherent caste-related inequality continues to dominate reality in Indian society. Much of the debate has focussed on reservation in educational institutions and employment, and rarely highlights the inequalities in health.
Social constructs: Many studies have documented that the caste system is a social construct in the absence of any real genetic differences among castes. Caste, in many ways, is similar to race, which is also a social concept without genetic basis. Nevertheless, these social constructs seem to have a stranglehold on human thought, perpetuating prejudice and propagating unjust societal structures.
Health indicators: Data from the National Family Health Survey-III (2005-06) clearly highlight the caste differentials in relation to health status. The survey documents low levels of contraceptive use among the Scheduled Castes and the Scheduled Tribes compared to forward castes. Reduced access to maternal and child health care is evident with reduced levels of antenatal care, institutional deliveries and complete vaccination coverage among the lower castes. Stunting, wasting, underweight and anaemia in children and anaemia in adults are higher among the lower castes. Similarly, neonatal, postnatal, infant, child and under-five statistics clearly show a higher mortality among the SCs and the STs. Problems in accessing health care were higher among the lower castes. The National Family Health Survey-II (1998-99) documented a similar picture of lower accessibility and poorer health statistics among the lower castes.
The poor, a majority from the lower castes, migrate to different parts of the country in search of work. Their migrant status means they lose many benefits generally offered to the poorer sections as their below poverty line and ration cards are not valid across State borders. The migrants find it difficult to register with the National Tuberculosis Programme at their place of work, resulting in out-of-pocket expenditure for treatment, discontinuation of medication when symptoms improve, relapse of the disease, medication resistance and premature death. Illness and its treatment usually wipe out all savings and are a common reason for indebtedness. Migrants are often considered vectors of communicable diseases and are not engaged by the public health system as they drive down indicators of health. The complete absence of schooling for their children implies a continuation of the cycle of poverty. Their inability to register with local electoral bodies means they fall off the radar of politicians and political parties.
Victims of communal violence: Dalits continue to face social discrimination and exclusion and are targets of communal violence. Assault, rape and murder of Dalits by the ‘upper’ castes are common and yet, frequently these crimes are not investigated and punished by the authorities, despite laws and protection provided by the Indian state. The Khairlanji massacre and the delay in its investigation come to mind. While many legal statutes exist, their implementation leaves much to be desired.
Health and human rights: There is an inextricable link between health and human rights. The violations of human rights (for example, violence) can have serious health consequences. The vulnerability to ill-health is reduced by taking steps to protect such rights (for example, freedom from discrimination and rights to health, education and housing). The World Health Organisation has strongly argued for a human rights-based approach to health to overcome the persistence of discrimination and human rights abuses.
Social determinants of health: It is widely recognised that the determinants of health are social and economic rather than purely medical. The poor health of people from the lower castes, their social exclusion and the steep social gradient are due to the unequal distribution of power, income, goods and services. Caste is inextricably linked to and is a proxy for socio-economic status in India. The restricted access of those from the lower castes to clean water, sanitation, nutrition, housing, education, health care and employment is due to a toxic combination of poor social policies and programmes, unfair economic arrangement and bad politics.
The structural determinants of daily life contribute to the social determinants of health and fuel the inequities in health between caste groups. Viewing health in general as an individual or medical issue, reducing population health to a biomedical perspective and suggesting individual medical interventions reflect a poor understanding of issues. Social interventions should form the core of all health and prevention programmes as individual medical interventions have little impact on population indices, which require population interventions.
Barriers to scaling up intervention: The major barrier to mainstreaming health care and to scaling up effective interventions is caste inequality based on socio-cultural issues. The systematic discrimination of lower castes based on culture, tradition and religion needs to be tackled if interventions have to work. Although the short time-lag between the (absence of) medical intervention and the health outcomes stands out as causal, it is the longer latent period and the hazier but ubiquitous and dominant relationship between caste and culture which have major impacts on outcome. Failure to recognise this relationship and the refusal to tackle these issues result in poorer health standards of the SCs and the STs. Tradition and culture maintain their stranglehold on inequality. Poverty and social exclusion have a multiplicative effect on the social determinants of health with those at higher risk for diseases also having a higher probability of being excluded from health care services.
The way forward: The World Health Organisation and its Commission on Social Determinants of Health recommend three principles for action: improving the conditions of daily life; tackling the iniquitous distribution of power, money and resources; and raising public awareness of issues, measuring the problems and evaluating actions. Providing supplemental nutrition and psychosocial stimulation improves physical and mental growth in underprivileged and stunted children. The provision of primary and secondary education and accessible health care regardless of the ability to pay is cardinal to success. Managing urban development with the provision of affordable housing, clean water and sanitation in addition to addressing rural land tenure and livelihoods is mandatory. The provision of fair and continuous employment and a universal public distribution system are necessary. The establishment and strengthening of universal social protection schemes are called for.
Continuing the current affirmative action in education and employment is crucial. Strengthening the mid-day meal scheme, the Sarva Shiksha Abhiyan, the Right to Education Act, the National Rural Employment Guarantee Act, the Food Security Act and the National Rural Health Mission, all steps in the right direction, is essential. There is need to increase resource allocation for the social determinants of health and to reinforce the government’s primary responsibility in providing for basic needs. Gender equity and social and political inclusion of the poor and lower castes in policy and decision making are required. Critics argue that an exclusive focus on production and trade without a viable distributive policy on food and land will not make poverty history.
The limits of liberalism: The spirit of socialism enshrined in the Constitution per se has not and will not result in equality of social and health outcomes for all people. There is need to change social structures. The many small moments of justice cannot overcome the large contradictions in Indian society. Liberals, by definition, can identify the issues but do not actively seek fundamental shifts in political power or enthusiastically champion changes in social mores. They are also part of the tyrannical social order.
Caste plays out in India just as race plays out in the U.S. and the social class in Britain. Birth seems to determine health, education, employment, social and economic outcomes. Systemic injustice requires much more than a change of heart; it requires changes in social structures. Social injustice is killing people and mandates the ethical imperative of improving the social determinants of health.
(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore, Tamil Nadu.)