Why caste, gender inequality worsen India’s public health crisis | Mint

Why caste, gender inequality worsen India’s public health crisis

A caste society militates against the very notion of a ‘public’ in the sense of a political community that works towards issues of common good. Photo: HT
A caste society militates against the very notion of a ‘public’ in the sense of a political community that works towards issues of common good. Photo: HT


Caste-based notions of purity and pollution stymie sanitation and go against the idea of a common purpose we must pursue

In the 19th century, all great Western cities were characterized by squalor and lack of public infrastructure. What happened then? Two lessons from global history: Public sanitation and solidarity: The explanation goes that economic prosperity resulting from the Industrial Revolution and colonialism was responsible for their transformation. The rise in incomes, however, was accompanied with endogenous processes of social change, working-class struggles towards better working and living conditions that led to a reorganization of urban spaces and secularization of knowledge production and its application to society. In Britain, for instance, the mid- to late 19th century was a period of the ‘Great Sanitation Awakening’, leading to a dramatic fall in mortality due to communicable diseases.

The key point in this story is that this mortality revolution took place well before the discovery of penicillin or mass production of antibiotics in the 1940s. It happened through classic and inexpensive public health interventions such as ‘public sanitation’ along with ‘public solidarity’, i.e., the coming together of social groups based on what public health ethicist John Coggon calls a “shared concern"—the realization that, for instance, the provisioning of drainage and waste management was good for everyone. Entire cities were almost built anew after this understanding gathered socio-political momentum.

A third lesson from recent research: The effect of low social status of women: V. Ramalingaswami and his colleagues famously argued in 1996 that contrary to popular imagination, it was not sub-Saharan Africa but South Asia that was worst affected by child malnutrition. They called it the “Asian Enigma". Why? Because, according to them, the answer to “South Asia’s high rates of child malnutrition is not to be found in the obvious". The obvious answer, i.e., poverty, even today fails to explain widespread open defecation or child labour across poor and rich states in India.

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According to them, it was the low social status of women that was responsible for India’s dismal record on nutrition. This is indeed confirmed by the recent performance of Bangladesh, often labelled “the other Asian enigma". Studies of the drivers of improvements there have highlighted the significant role played by gender equality. The central question then is why has India failed to follow these lessons that can improve the basic social and well-being indicators of its population?

Caste harms everyone: Health research in India largely seems to be satisfied with poverty as the explanation for miserable social indicators. Studies on health outcomes either ignore caste or apply it merely as a label to demonstrate differential burdens of, for instance, malnutrition and disease. In contrast, I argue that the ideology of caste, especially its dual principles of purity and pollution, has grave implications for public sanitation. Open defecation or a filthy neighbourhood is accepted if ritual purity—the absence of things considered impure such as human faeces—is maintained within the household. Certain castes ostracized as “ritually impure" are forced into sanitation work. For other castes, it offers perverse incentives to stay far away from working towards public cleanliness. In this way, basic civic sense is discouraged, even stigmatized, in a caste society.

More generally, a caste society militates against the very notion of a ‘public’ in the sense of a political community that works towards issues of common good. The writings of B.R. Ambedkar tell us how this happens. Caste works against social endosmosis—the possibility of various channels of exchange of experiences between social groups—and enforces “social isolation" for oppressed groups, who are blocked out of social communication, resulting in loss of empathy and ethical responses from other castes. Therefore, even the most progressive and scientific-minded individuals—who are socialized in caste, after all—do not define all-pervasive manual scavenging in our society as their enemy number one, thus thwarting urgently needed socio-political and scientific revolutions against this most inhuman system.

But the caste system does not only resist the interests of oppressed castes. In working against feelings of mutual trust and fellowship in society, it ironically prevents even the elite from helping itself, in terms of elimination of communicable diseases through a sanitation revolution, provisioning of open spaces, clean air and neighbourhoods, etc. The beauty and strength of public systems lies in the fact that caring for others translates into caring for oneself. This is not to be seen in a caste society, though.

It is not that the Indian elite does not see the problem, but its solution is to increasingly ‘privatize’ and gate-ify roads, housing, water, schools, transport and, more recently, even air. As observed during the covid pandemic, they also do occasionally realize it is impossible to completely insulate oneself from the larger society. But the absence of a feeling of belonging to the same ‘public’ in India precludes the possibility of replicating what happened in the West during the 19th century. In this way, everyone is harmed, as public health, by definition, is the entire population’s health.

Caste (and gender inequality): A public health crisis in India?: Anyone studying Indian society cannot think of gender without thinking of caste. B.R. Ambedkar, in his earliest treatise on caste in India, had argued that control over women was central to maintaining caste purity. Even today, women have limited control over decisions regarding their own bodies, such as sexuality, choice in marriage or childbirth. Violence against women takes varied forms and ‘honour killings’ are as much about caste/clan as they are about gender. Given this, it is not shocking that India has one of the lowest female labour force participation rates in the world, comparable to some west Asian and north African regions.

Professors John Coggon and Lawrence Gostin recently pondered two questions in public health: a philosophical one of what makes health public, and second, how we could make health public—or an activist-y concern, so to say. In our case, the joint operation of caste and gender collides with the philosophical and activist-y.

During the covid pandemic in October 2021, the New York City Board of Health declared racism a “public health crisis". Given what we have gone through during the covid pandemic, can we make a start by declaring caste and gender inequality a public health crisis in India?

Awanish Kumar is British Academy Newton international fellow, University of Edinburgh.

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