India’s inequality in healthcare: the caste divide

28 January 2016


The last couple of weeks have seen an increase in media awareness of the discrimination faced by Dalits, the people below the lowest caste, in India.

The suicide of Dalit student, Rohith Chakravarti Vemula, on Sunday 17th January 2016 has sparked protests and campaigns on the treatment of Dalits across India and particularly in Hyderabad, the city where Rohith studied and was expelled from student housing along with four other Dalit students.

Hyderabad is also the location of Operation Mercy India, HART’s partner in India, which provides medical care to marginalised groups such as Dalits.


How is discrimination against Dalits perpetuated in society?

For centuries, Dalits have been outcast from society and labelled as ‘untouchables’. Despite numerous laws created since 1850 to protect Dalits and end caste-based discrimination, segregation can start at an early age at school. There was a recent report of coloured wristbands being used in a school to differentiate between students from different castes.

The caste system is thus reinforced and perpetuated through the education system; there are additionally reports of many students who drop out due to severe discrimination. This BBC article reports:

“There is systemic persecution of Dalit students in Indian universities. They are often failed by their teachers deliberately”.

Rohith’s suicide was by no means the first: there have been eight other suicides in the last 10 years at Hyderabad University linked to caste politics.

Dalits in India (4)

Not only are Dalits segregated in the classroom, but also in their home environments; the majority of Dalits in rural areas live in segregated colonies, away from the higher castes. Even in urban areas, government-based programs for Dalit housing maintain the separation between castes. This form of segregation has led this caste-based discrimination to be named India’s ‘hidden apartheid’ by Human Rights Watch (HRW).

What is the impact of ‘untouchability’ on Dalits’ health?

The segregated colonies are forced to use water facilities which are not shared by higher castes; as a result, more than 20% of Dalits do not have access to safe drinking water. This can result in fatal illnesses such as malaria, cholera and diarrhoea, which severely affects child mortality as diarrhoea is the second leading cause of child death in the world.

The problem of water facilities affects Dalit women more than men since traditionally it is the role of the women or girls in a family to collect water, often at the cost of education. For a Dalit woman, this role is dangerous as they are often victims of verbal and physical abuse from higher castes during the long journey on foot to fetch water. It also poses a health risk, as Dalit women spend half their calorie intake in this task, yet the amount of water they collect can be very little as it is often up to the dominant caste members who control the public wells and taps.

Both of these elements – a lack of education and poor sanitation – are contributors to illness. Limited education leads to fewer employment prospects, and therefore less economic empowerment to be able to pay for healthcare or the transport to travel to a health clinic.

Working with human waste

Moreover, Dalits are also forced into dangerous work which has little or no pay. An example of this is manual waste scavenging which involves cleaning human excrement from open defecation sites, gutters, and drains, as well as cleaning sewers and septic tanks.

The workers are not provided with equipment to protect their skin from the excrement and as a result diarrhoea, vomiting, jaundice, trachoma and carbon monoxide poisoning are just some of the health consequences. In a report by HRW, a woman, Neha, employed by the municipal corporation in Bharatpur city in Rajasthan to manually remove excrement flushed into open drains, told HRW:

“We don’t get anything from the government. No mask. No gloves. Nothing to prevent diseases when the excrement comes in contact with our hands and legs. Ten years ago before I started this work I was much healthier. Now I get sick often.”

In other interviews conducted by HRW, a Dalit woman tells the interviewer about how she had a miscarriage due to the heavy loads of excrement she was forced to carry on her head. Of course, the health issues are then further exacerbated by the Dalits’ inaccessibility to healthcare treatment.

Despite the dangers, workers are trapped in this extremely degrading job and are even threatened with violence to make them continue the work. A significant number of workers who do leave the job consequently face barriers for accessing housing, employment and support from government programs.

The Dalits interviewed by HRW explained that they have limited employment opportunities due to discrimination against them from birth.Sona from Bharatpur city explains this:

“The first day when I was cleaning the latrines and the drain, my foot slipped and my leg sank in the excrement up to my calf. I screamed and ran away. Then I came home and cried and cried. My husband went with me the next day and made me do it. I knew there was only this work for me.” (from HRW report ‘Cleaning Human Waste’)

This systematic discrimination and lack of choice led Ashif Shaikh, founder of the Rashtriya Garima Abhiyan, a grassroots campaign against manual scavenging to say,

“The manual carrying of human feces is not a form of employment, but an injustice akin to slavery.”


What is the impact of ‘untouchability’ on healthcare for Dalits?

Dalits are therefore more susceptible than higher caste members to contracting illnesses. However, they cannot receive the healthcare that they need, either due to their poverty or society’s discrimination which both act as barriers.

The fact that Dalits have been labelled as ‘untouchable’ means that they are discriminated to such an extent that The Untouchability in Rural India survey found that Dalits were denied entry into private health centres or clinics in 21.3% of villages. Research also reveals that healthcare workers also do not go into 65% of Dalit communities, thus leaving many Dalits without any choice but to go without healthcare.

The impact of ‘untouchability’ on Dalit Women’s healthcare

For Dalit women, the predicament is even worse. As UNICEF stated: “Dalit women have to face three pronged discrimination – they are women, they are Dalits and then they are Dalit women.” In India, These women are often denied access to healthcare and justice. Sexual violence is perpetuated by society because Dalit rape cases are often not investigated or even recorded. Additionally, the National Human Rights Commission of India has reported that there are many cases of sexual assault and rape by police with the aim to punish Dalit communities. There are also instances when police have raped Dalit women during raids in order to exert pressure on their families to give false evidence or surrender.

Maternal healthcare is also hugely affected due to frequent discrimination by auxiliary nurse mid-wives and community health workers. For example, in Uttar Pradesh, ‘untouchability’ is practised to such an extent that pregnant Dalit women do not receive health care, thus leaving women to give birth without the presence of a trained birth attendant. This can be fatal for both mother and baby, especially in cases of complications during labour.

MUMBAI, INDIA: Low-caste Hindu - dalit or the oppressed - women wait for medical treatment at a homage site in Mumbai, 06 December 2006. More than 200,000 Hindus at the bottom of India's caste hierarchy gathered in the financial hub Mumbai to pay tribute to their iconic leader B R Ambedkar, a low-caste Hindu who fought against discrimination and who died 50 years ago. In a yearly ritual, low-caste Hindus gather at Ambedkar's 'Chaityabhoomi' (pure-land) memorial in central Mumbai from across western Indian state Maharashtra and neighbouring states. Security forces were on high alert across Mumbai after caste riots claimed four lives last week. AFP PHOTO /Sajjad HUSSAIN (SAJJAD HUSSAIN/AFP/Getty Images)
Dalit women wait for medical treatment at a homage site in Mumbai SAJJAD HUSSAIN/AFP/Getty Images

How far-reaching is the injustice against Dalits in healthcare?

It is not only patients who are discriminated against; doctors and midwives, among other professionals from different occupations, are boycotted due to their ‘untouchability’. There is a shocking level of abuse against Dalits at Dehli’s All India Institute of Medical Sciences, India’s leading medical school, from students, tutors and examiners, who routinely fail their students deliberately, making it more difficult for Dalit students to become doctors.

The vicious cycle of prejudice against Dalits means that they are rejected from all spheres of healthcare in India, turning healthcare into a luxury affordable and accessible only for those lucky enough to be born into the right families.

Why hasn’t this injustice been abolished?

Despite laws abolishing caste-based discrimination, for example the Protection of Civil Rights Act 1955 and The Scheduled Castes and Scheduled Tribes (Prevention of Atrocities) Act 1989, the tradition is yet to be abolished and laws implemented fully. But in the current state where even law-enforcers, such as the police, can be said to be perpetrators of discrimination themselves, India is far from an equal society.

There are numerous examples of Dalits changing their surnames to hide their caste in an attempt to gain equality in India by escaping the caste prejudices. An article by Al Jazeera stated that there are even cases of Dalits converting to other religions from Hinduism, from where the caste system originates.

Many Dalits are unaware of their legal rights, for example the right to refuse manual scavenging work. Arguably even if they were aware of their rights, they wouldn’t necessarily be able to implement change. Although 16% of the Indian population is constituted of Dalits, Avatthi Ramaiah from the Centre for Study of Social Exclusion and Inclusive Policies reveals that:

“they [Dalits] constitute too small a number in each village to confront the upper castes, pressurise the police to ensure their legal protection, or otherwise mobilise against caste oppression. They are also divided among themselves on sub-caste lines, though to a lesser extent. It also doesn’t help that most Dalits are landless and depend on the very castes that violate their rights to earn their livelihoods.”

Perhaps the current rise in demonstrations and protests since Rohith’s suicide will be a catalyst for change in modern-day India.

Photograph by Digvijay Shah published on BBC
Photograph by Digvijay Shah published on BBC

What is HART doing about this?

HART began supporting Operation Mercy India in 2008 and currently helps to fund the Jeedimetla Medical Clinic in Hyderabad. This clinic works with those who are poor and marginalised, including Dalits, slum dwellers, migrant workers and victims of trafficking. Since 2010, it is also a testing centre for HIV and AIDS. The project also encompasses a mobile clinic which goes into slums and provides medical care particularly for vulnerable women such as the Devadasi – women who have been forced into temple prostitution.

 In just three months at the end of 2014, 2953 patients were seen in the clinic and a further 1223 patients were seen in medical camps in the slums.

Click here for more information about Operation Mercy India:

Text HART00 £10 to make a £10 donation to HART.


Disclaimer: This blog is a space for discussion and personal reflection. Any opinions expressed within the blog are those of the author and are not necessarily held by HART. Individual authors are responsible for the accuracy of statements made within the blog.


Back to News

Help our local partners realise their vision of hope for their communities