What are the caste biases of the Indian healthcare system? How does casteism affect medical education and practice? What happens when you seek help and are told that casteism is not real? In this lucid essay, Dr. Kiran Valake offers a ringside view on the intersections of caste, mental health, and access to care.
The Covid-19 pandemic has successfully exposed the fault lines in an extremely underfunded and neglected Indian healthcare system. More importantly, it has accentuated the inherent caste biases of the healthcare industry as well. Exactly like the graded inequalities in the caste system, there exists a hierarchy within hospitals that is seldom spoken about. A doctor, almost always a cisgender man, and more often than not belonging to the oppressor castes, usually occupies the upper echelon of this hierarchy. On the other end of the spectrum are the sanitation workers, mortuary staff, ward boys and housekeeping teams – most, if not all, belonging to the oppressed castes along with their own gender-based roles. When doctors were showered with flower petals, a lot of these workers silently worked their fingers to the bone, oftentimes without even the most basic of personal protective equipment. Many perished, leaving their families to fend for themselves. Their deaths have not been accounted for.
The overworked and underpaid foot soldiers of the Indian healthcare system – the ASHA workers – seldom get the respect they deserve. During the pandemic they have had to go from door to door in remote locations, convincing an increasingly sceptical population of the need to take the Covid-19 vaccine. They regularly face threats of sexual harassment and physical violence. A 2015 study, looking into the dynamics of ASHA workers in Karnataka, found that an overwhelming majority belonged to socially disadvantaged castes.
As much as people would like to deny it, caste plays a pivotal role in the way the healthcare industry functions – everything, from the way reserved category students are treated in colleges, to the way medical professionals are treated during their clinical careers. Dr. Sobin George, in his paper titled Caste and Care: Is Indian Healthcare Delivery System Favourable for Dalits? looked into the social dynamics of caregivers in healthcare institutions. He posits that the abundance of caregivers from oppressor caste groups has encouraged and sustained an environment that breeds casteism. Dr. George argues that one way of dealing with this issue is by having adequate representation of oppressed caste individuals at all levels of the healthcare industry.
Discussions around epistemic injustice are often replete with examples of women’s voices being dismissed or taken less seriously only because of their gender. Although these examples are justified, there is reluctance, and often even resistance, to extrapolate the same to a person’s caste location. Students from the oppressed castes have had to work harder to counter the inherent biases of their colleagues and seniors. They fear that these biases will follow them throughout their clinical careers, and they will forever have to play catch-up with a misplaced sense of merit that is often held by their oppressor caste colleagues. It is not hard to imagine the kind of mental trauma this sustained need for redemption, and acceptance, puts on an individual. The imposter syndrome that goes along with medical education is debilitating at the best of times. From personal experience, I can attest that these feelings of unfounded inadequacy are often more prevalent among oppressed caste students, which is not surprising when your credibility as a knower is brought into question at every opportunity. I have been fortunate in this regard since my surname is ambiguous enough to not give away my caste location immediately. (In retrospect, the verbal gymnastics that people often perform to figure out my caste seems funny.)
Any discussion with an oppressor caste student around caste is incomplete without a comprehensive dissection of caste-based reservations. Invariably, the merit of oppressed caste students is brought into question. Every year like clockwork, during the medical entrance exam season, banal hashtags like #MurderOfMerit, and #SaveMeritSaveNation do the rounds on social media with complete disregard for the effect this may have on students from reserved categories.
These aren’t just hushed water cooler discussions – they are on WhatsApp groups, on Facebook posts, in hostel rooms, and sometimes even by faculty members themselves.
Their arguments are however quickly shot down by those that are unaware of, or unwilling to understand, their plight. On the rare occasions when such instances of subtle or even overt casteism are brought to the attention of the appropriate authorities within the institution, they are often brushed off as hazing or ragging. Students have had to put up with a lot of insolent and violent behaviour under the garb of ragging, which although strictly prohibited, is considered to be a rite of passage by many. Mischaracterising casteist slurs as ragging is just another way of pretending institutional casteism does not exist.
Although a lot gets said and written about caste discrimination faced by students in institutes of higher learning, not enough attention is given to discrimination of faculty members belonging to the oppressed castes. Prof. Vipin P. Veetil, an assistant professor working at IIT Madras in the Department of Humanities and Social Sciences, resigned in July 2021. Not only did he face caste-based discrimination but he was also brazenly asked to take it up with the appropriate authorities, knowing full well that the system in itself is inherently biased, and nothing was ever going to come of it.
One would expect death to be the great equaliser – ashes to ashes, dust to dust. Nothing however, could be farther from the truth – and this has been made amply evident during the ongoing pandemic. Societal disparities have dictated everything from access to life-saving drugs and medical facilities, to even burial grounds after death.
During the recent civil unrest in the U.S., and protests that followed the institutional murder of an unarmed black American man, George Floyd, at the hands of a white police officer in 2020, multiple monuments associated with the Confederacy – stark reminders of racial injustice – were vandalised or officially removed. The perpetrators of George Floyd’s murder were brought to justice and are now looking at long prison sentences. I wonder if the same speed and efficiency can / should be expected from the Indian judicial system when dealing with instances of systemic caste-based discrimination of oppressed caste individuals. May 2021 marked two years since Dr. Payal Tadvi, an Obstetrics and Gynaecology resident at Nair Medical College, Mumbai, died from suicide. Dr. Tadvi’s mother, Abeda Tadvi, continues her fight for justice.
In 1959, Dr. Martin Luther King, Jr. travelled to India along with his wife, and was welcomed by the then Prime Minister Jawaharlal Nehru. He visited a school in Thiruvananthapuram, Kerala, where students from ‘untouchable’ families studied. The principal, while introducing Dr. King to the students, had used the phrase, “fellow untouchable from the United States of America”. Dr. King, although initially displeased with this designation, later realised the subtle connections between his position as a Black man in the United States, and the position of the students he had come to meet, in India. In instances like these, the lines between racism and casteism seem to blur a little.
However, in her 2020 book titled, Caste: The Origins of our Discontent, Isabel Wilkerson posits the subtle differences between caste and race. She says, “Caste and race are neither synonymous nor mutually exclusive. They can and do coexist in the same culture and serve to reinforce each other. Race, in the United States, is the visible agent of the unseen force of caste. Caste is the bones, race the skin. Race is what we can see, the physical traits that have been given arbitrary meaning and become shorthand for who a person is. Caste is the powerful infrastructure that holds each group in its place. Caste is fixed and rigid. Race is fluid and superficial, subject to periodic redefinition to meet the needs of the dominant caste in what is now the United States.”
Therein lies the fundamental difference between race and caste. On the one hand where it may be easier for a white man to support, and even actively take part, in bringing down Confederate monuments in America, in India a statue of Manu, whose Manusmriti is considered by many to be the epitome of discrimination, continues to adorn the grounds of the Rajasthan High Court to this very day.
If one were to wade through the myriad of reviews and critiques of Wilkerson’s book, one would realise that making comparisons between caste and race can sometimes be a risky affair. Authors often have to walk a tightrope in doing so.
There is ample research suggesting that experiencing racism is associated with poor physical and mental health outcomes. This results in poorer health outcomes for ethnic minorities, and people of colour.
‘Anti-oppressive practice’ is an emerging framework for psychotherapy and counselling that challenges oppressive power structures that perpetuate a system of racism. This framework has often been implemented to challenge other intersecting forms of structural oppression as well.
However, in the Indian context, studies looking into the adverse mental and physical health outcomes of people from oppressed castes experiencing individual and systemic casteism are few and far between.
American medical student and science communicator LaShyra Nolan writes about how medical education is inherently racist in this paper titled How Medical Education Is Missing the Bull’s-eye. In it the author discusses how students are only ever taught about diagnosing medical conditions in fair-skinned individuals. In the Indian context we have not even begun to have similar conversations. How are we to rectify a problem we are unwilling to accept the presence of?
Here is a parallel. The Mariwala Health Initiative is a Mumbai-based organisation that does a wonderful job of equipping mental health professionals with adequate knowledge to cater to the needs of their queer clients. Their course on Queer Affirmative Counselling Practices (QACP) has been instrumental in this regard. They believe it is not enough for mental health professionals to merely be queer-friendly when working with queer clients.
Along the same lines, caste-affirmative counselling practices need to be developed, although at present this definitely seems to be an uphill task. Mental health professionals (MHPs) coming from an oppressor caste are often unable to dismantle their own caste privilege, and unwilling to look at casteism as a significant contributor to mental distress in an individual. Working intimately with The Blue Dawn, a mental healthcare support group for Bahujans, has made me privy to several such instances.