In late November 2014, the esteemed British medical journal The Lancet published an editorial calling for the end of casteism in India to mitigate the deteriorating health of the millions of rural poor, if nothing else. The central argument was that caste was hampering access to healthcare services. Caste has been blamed for hampering many things. As Amartya Sen and Jean Dreze write in An Uncertain Glory (2014), “… caste continues to be an important instrument of power in Indian society, even where the caste system has lost some of its earlier barbarity and brutality”.

To append healthcare to that list wasn’t a big leap because casteism in India has had a tendency to graduate access to the fundamental rights even. The editorial cites a lecture that the social activist Arundhati Roy gave last year, during which she mentions the example of a doctor who wouldn’t treat a patient because the latter is of a lower caste. At the same time, the appending had to be a controversial leap because it implies that those who are responsible for the ineffectual provision of healthcare services could in some way be ignoring – or even abetting – casteist practices.

Anyway, three responses to the editorial (whose links are available on the same page) provide some clarity on how caste contributes directly and indirectly to the country’s distinct health problems by interfering in unique ways with our class divisions, economic conditions and social inequalities. They can be broadly grouped as age, inheritance and wealth.

1. Age

The first letter argues that the health effects of caste are best diagnosed among older people, who have been exposed to poverty and the effects of caste for a lifetime. Citing this study (PDF), the correspondents write:

The study reported that several health measures, including self-rated overall general health, disability, and presence of a chronic disorder, are similar between scheduled tribes, scheduled castes, Brahmins, Kshatriyas, Vaishyas, and Shudras in people aged 18–49 years. However, people aged 50 years and older in scheduled tribes and castes were reported as having poorer self-rated health and generally higher levels of disability than those in less impoverished groups, which suggests that the longer the exposure to poverty, the greater the effect on the ageing process.

However, there is an obvious problem in assessing older people and attributing health concerns unique to their age to a single agent. Hindus, who comprise the religious majority in India, traditionally revere their elders. The young are openly expected to ensure that their elders’ economic security and social dignity are not significantly diminished once they retire from full-time employment. Such promises on the other hand are not prevalent in other religious groups. To be sure, that “longer exposure to poverty leads to more health drawbacks” is not entirely flawed but the intensity of its effects may be confounded by traditional values.

2. Inheritance

A paragraph from the second letter reads,

People should only marry within their caste, which can lead to consanguinity. This antiquated tradition has resulted in an unusually high prevalence of specific autosomal recessive diseases in specific community or caste populations, such as diabetes, hypertension, ischaemic heart disease, mental impairments, mental illness, spinocerebellar ataxia, thalassaemia, and sickle-cell diseases.

While increasing literacy rates, especially among the younger age groups, are likely to reduce caste gaps in literacy over this decade, caste seems to have left some population groups with an unenviable inheritance: of the effects of detrimental biological practices. One of the studies the letter’s authors cite provides a p-value of 0.01 for consanguinity being a determinant of diabetic retinopathy (that’s strong evidence). And inter/intra-caste marriages are a prominent feature among caste-based social groups.

3. Wealth

The author of the third piece of correspondence is disappointed that The Lancet saw fit to think dismal healthcare has anything to do with caste, and then adds that the principal determinant across all castes is economic status (on the basis of a 2010 IIPS study). In doing so, two aspects of the caste-healthcare association are thrown up. First, that casteism’s effects are most pronounced on the economic statuses of those victimized by its practice, and that is one way of understanding its effects on access to reliable healthcare. Second, that the statistical knife cuts the other way, too: how do you attribute an effect to caste when it could just as well be due to a failure of some other system?

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