Caste and public health
What explains the paradox that India, one of the most advanced among
developing countries, has one of the worst public health systems? It appears that the uniquely perverse institution of caste, coupled with the pursuit of a neoliberal economic agenda, explains this glaring
abnormality.
INDIA IS ONE OF THE WORLD’S LEADING destinations for medical tourism, and yet it ranks abysmally low in terms of child and maternal nutrition in the world. The ongoing COVID-19 pandemic has made it all too plain that the deep socio-economic inequality in Indian society is starkly reflected in the way it provides access to health care. Whereas well-heeled Indians seem to be basking in a long holiday under the lockdown, poor working Indians are in a state of unemployment and hunger, having lost their dignity, and in utter despair. This then is the time to raise sharp questions: Why has it taken so long for Indian society to even comprehend the
very notion of public health, something that has been obvious for over a century in the West? And, why and how has India’s uniquely distinctive institution of caste played a subversive role in preventing this from taking root?
In an everyday sense, particularly in a society with little or inadequate historical experience of a well-functioning public health system, health is defined in a negative sense, that is, a person is considered healthy if she is not ill. Health is often reduced to health care, provided and accessed either in the private or public realms/sectors or a mixture of the two. However, COVID-19 has exposed the sheer vacuity of this logic. Most people will now readily concede that health is much more than simply not being ill at the individual level. In an understanding geared towards “public” health, health is defined very differently. The World Health Organisation (WHO) in 1948 defined health as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity”. Later definitions emphasised the dynamic nature of health and its social determinants, for instance, caste, class and gender in the Indian context. Many people have noted that health must be understood as a universal entitlement of all human beings; some have argued that health must be considered a human right. Professor Lawrence O. Gostin, a wellknown public health ethicist from Georgetown University in the United States, argues that health is produced in three overlapping spheres: one, health care, that is, individual clinical services; two, socio-economic determinants including but not limited to fair distribution of income, jobs, housing, and social justice; and three, public health, to which I now turn.
Before discussing public health, I will illustrate the previous points through a few examples. Think about tuberculosis: it is widely considered a disease of the poor. Globally, about three-fourths of all TB deaths occur in low-income countries; in 2019 India had an estimated 27 lakh TB cases. The relationship between poverty and TB is obvious: poor nutrition, inadequate ventilation, and overcrowded housing and work conditions significantly heighten the risk and rate of TB infections. This reasoning applies equally well to starvation deaths in poorer regions of the country or even the exceptionally high rates of anaemia among Indian women or malnutrition among Indian children.
These have macro political implications, too. In nations with certain specific historical conditions, institutions and solidarity mechanisms, comparatively less money spent on health produces better health outcomes. Compare Cuba and the U.S, for example. Cuba spends only about 8 per cent (of which 91 per cent is public expenditure) of its gross domestic product (GDP) on health, whereas the U.S. spends about 15 per cent (of which only 56 per cent comes from public expenditure) of its GDP on health. The life expectancy at birth in both countries is 78 years and, in fact, the Infant Mortality Rate (IMR) in Cuba is lower at 5 versus 7 per 1,000 in the U.S. What does this comparison reveal? It shows us that the social organisation of health is perhaps even more important than the economics of health care. Research from various quarters has shown that public health systems cannot be understood without reference to the underlying socio-economic, political and cultural context of a country.
PUBLIC HEALTH IN THEORY AND HISTORY
Public health, in a general sense, has many meanings. In the most literal sense, public health refers to the health of a population. This is important as it takes the discussion on health away from the individual and towards a group or a community. As a philosophy, public health aims at making interventions to achieve good health at the level of the population. Prof. John Coggon from the University of Bristol in the United Kingdom argues that public health is essentially a moral and political agenda. He argues that the “public” in public health is a reflection of a “shared concern” of a political community. In Coggon’s perspective, there is a striking emphasis on the collective and group identity that is built upon shared interests. This shared interest is an outcome of one, or a combination, of the following: specific historical conditions, socio-cultural institutions, force of ideology and political organisation.
Let us take the case of Britain and see how a combination of historical conditions and active political forces created the National Health Services (NHS) in the postsecond World War period. The long history of public
health in the European continent goes back to the black deaths during the 14th century that killed more than 25 million people in Europe alone. In fact, very few people know that the word quarantine, now in vogue, comes from “quaranta”, which is Italian for the number forty. During the plague epidemic of 1348, the city state of Venice did not allow any ship to enter its territory until they had completed the mandatory detention period of 40 days at the coast. This was to ensure that the epidemic was kept at bay, quite literally, albeit unsuccessfully!
This series of deadly epidemics continued until the early modern period in Europe, when a new understanding about the relationship between disease and society emerged. As the Industrial Revolution gathered pace during this period, the state and the elite were engaged in the process of “social engineering” in order to deal with the unprecedented changes brought by industrialisation. Here, industrialisation necessarily meant the unprecedented impetus to urbanisation, following the organisation of work in factories, which necessitated a scale of demographic relocation unseen in earlier history and which meant a sharp increase in the population density in urban centres. The literature from this period, most poignantly, for instance by Charles Dickens, speaks of the massive upheavals in the lives of ordinary people and working classes and the resulting social unrest. However, there were some important institutional arrangements from the past that provided the basis for further improvements in the way health was administered in England. First, there was the legacy of the numerous Poor Laws enacted since the 16th century, especially in 1572 and 1601, which, at least theoretically, recognised the importance of social solidarity for alleviating poverty. Specifically, in the field of public health, local governments, religious and charitable organisations and cooperatives provided health care to those in need.
The cholera epidemic in 1832 played an important role in the promulgation of the Poor Law Amendment Act in 1834 and eventually led to the passage of a Public Health Act in the year 1848. The latter focussed on some typical public health activities such as providing improved ventilation to workers, construction and maintenance of drainage, cleaning of streets and public wells, fumigation and waste management. Meanwhile, workers were getting organised and working-class activism was growing rapidly, which put pressure on industrial employers and the state to improve working and living conditions for all.
Friedrich Engels in his The Condition of the Working Class in England (1844) linked living and working conditions such as sanitation, overcrowding, and the lack of ventilation with the spread of epidemics in working-class settlements. A number of influential scientists such as Rudolph Virchow in the U.S. and civil servants like Edwin Chadwick in the U.K. emphasised the social and political aspects of such epidemics. An important figure during this period, John Snow, established in his On the Mode of Communication of Cholera (published in 1849) that one of the most important aspects of preventing cholera was to ensure that drinking water channels did not get contaminated by waste-carrying drains. This entire period of mid to late 19th century is called “the great sanitation awakening”, characterised by a sanitation movement in British history.
It is interesting to note that the early period of this awakening was not informed by drastic progress in humanity’s understanding of how diseases spread or even the mass production of medicines (also known as the therapeutic revolution). A great deal of knowledge available in those days about diseases and how they spread was patently wrong. It was understood that foul smells carried diseases—which is also at the root of the term “malaria”, literally meaning bad air. As we know, it was only in the year 1873 that Louis Pasteur proposed the germ theory of disease, which propelled the sanitation revolution that resulted in a dramatic fall in mortality due to communicable diseases in England and Wales: from 31 per cent in 1871 to 10 per cent in 1940.
The key point here is that this decline in mortality rates took place well before the discovery of penicillin in 1941 or the therapeutic revolution of the 1950s. This “mortality revolution” can be attributed to classical and inexpensive public health measures adopted by the state in Britain. By the early 1950s, the share of infectious
diseases in total mortality in Britain had come down to a mere 6 per cent. The British situation had changed dramatically by the mid 20th century via the epidemiological transition that resulted in the preponderance of non-communicable diseases and almost a complete disappearance of the infectious ailments of the 19th century. In the same period, the National Health Service (NHS), based on the William Beveridge report of 1942, was founded in 1945 whereby health became a responsibility of the government.
The category of health care/services as commodities emerged only after this epidemiological transition and the therapeutic revolution was completed in the West in the mid 20th century. Since the Western world was the leader in knowledge creation and research and development (R&D), their priorities shifted from classical and already-achieved public health concerns to newer and more immediate medical issues such as cardiovascular and lifestyle-oriented diseases, which had grown in proportion since the 1950s. In contrast, the Global South, having failed to make this transition, continues to struggle against the onslaught of infectious diseases, which affect mainly the poor there. However, instead of addressing these issues, most developing states have succumbed to the global health care and the pharma industry along with their own national elites in prioritising secondary and tertiary health care services at the expense of battling mass killers such as malaria, dengue and TB, among others. This has been abetted by the privatisation of health care in the Global South, where lifestyle diseases afflicting the rich are avenues of profiteering by “super-specialty” hospitals and the like.
PUBLIC SANITATION, PUBLIC SOLIDARITY
We can derive two key lessons from the history of public health in Britain and Western countries more generally. The first is that a substantial part of the progress in terms of decline in mortality and advance in living and working conditions can be attributed to the classic and inexpensive public health interventions in drinking water supply, drainage, sanitation and housing. This lesson can be called a lesson in public sanitation. The second lesson relates to the emergence of the welfare state and the NHS in Britain.
In Michael Moore’s acclaimed movie Sicko (2007), he interviews Tony Benn of the old Labour Party. Benn highlights how the NHS came into being through democracy, that is, the movement of social and political power from the marketplace to the polling station. Julian Tudor Hart, a practising doctor for many years in Wales, member of the Communist Party of Great Britain and authority on the history of the NHS, argues that the nationalisation of all hospitals as part of the NHS was central to its success. This, he says, created “a single, unified workforce aiming at common standards and with centrally negotiated pay… a sense of collective participation in a civilising enterprise for the entire U.K., and loyalty to a nationally shared idea”. The doctors, other professionals, patients and the public at large felt a sense of ownership towards the NHS. The feelings of reciprocity that are inherent in mutual trust between people ensured that social and political solidarity was not considered as altruism but common good. This is very similar to the framework proposed earlier to understand the notion of public health as shared concern and common interest. Thus, the second lesson can be called one in public solidarity.
What prevents India from learning from and adapting these two simple lessons from the public health theory and history, namely public sanitation and public solidarity?
In the days when William Beveridge was preparing his report recommending the formation of the NHS in Britain, India, too, had its own Joseph Bhore Committee (1946) that, in its report, envisioned an Indian NHS. However, that was not to be. As we know, even the Constitution of India relegated both public health and education to the non-mandatory Directive Principles of State Policy. The lack of seriousness of the Indian state towards health in general can be gauged by the fact that the first ever health policy statement surfaced only in 1983, 36 years after Independence and five years after the Alma-ata Declaration that called for the universalisation of primary health care. The Indian state, after Independence, was unwilling to invest in either public education or in a well-functioning public health system. The agenda of the state was heavily influenced by the upper castes’ outlook; the state thus lacked the conviction to bring about thoroughgoing social and economic reforms. Social policy, in particular, the promotion of health and education, was completely ignored. Social reforms that had the potential to create public systems in the new republic thus remained stillborn.
The late 1980s and early 1990s witnessed the emer
gence and dominance of neoliberal policy, especially in soft sectors such as health and education. A serious engagement with the primary health care system in India only came about with the National Rural Health Mission (NRHM) and the National Health Mission (NHM) after 2005. Yet, even after massive increases in expenditure through these programmes, the Indian government’s expenditure on public health still hovers around one per cent of the gross domestic product (GDP). The out-ofpocket expenditure (or, in other words, spending on health that comes from one’s own personal resources in the form of personal savings or borrowings or sale of assets) continues to be about three-fourth of the total health expenditure, which disproportionately burdens the poor. India presents a unique case: the dominance of two ideological forces, caste and neoliberal capitalism, which actively prevent popular mobilisation around the agenda of promoting public health.
CASTE, SANITATION AND SOCIAL CONTROL
Indian society is constituted by castes, underpinned in the Hindu religion. The caste system, according to B.R. Ambedkar, is a system of organising people through a graded hierarchy. There is no free entry into or exit from any caste to another. The basic principles of the ideology of caste can be explained through the twin principles of purity and pollution. Both terms are defined in terms of their ritual implications, and therefore it is possible for something to be clean and yet be ritually impure and vice versa. This notion of cleanliness is most apparent in the case of open defecation where constructing a toilet inside the house is considered ritually impure, but defecating in the open is unproblematic as far as ritual purity is concerned. Additionally, in this understanding, certain objects and persons can be pure and certain others polluting. That is why cow ghee can be considered inherently pure, whereas persons below the caste and varna one belongs to can be polluting in different gradations.
This framework of purity and pollution has many implications for public policy, especially the first lesson outlined above—public sanitation. First, this impacts the distinction between private and public spaces. As one can see from the previous example, the fact that open defecation can be a public hazard does not inspire the castetrained mind to abstain from it as long as ritual purity— absence of impure human faeces—is maintained within the household. It does not occur to the caste-trained mind that the public space would be left both unclean and prone to disease, and “ritually impure”. A lot of people would discard this example as having repercussions only for rural populations. To counter this, let us take the example of garbage disposal in urban areas, even in upper middle-class locations. The dichotomy of purity-pollution is evident here, too, in the way garbage is thrown out of balconies, car windows and buildings without any thought about the overall implications of an unclean neighbourhood.
Secondly, this perspective ostracises and criminalises persons on the basis of how “ritually pure” or “impure” they are on the graded scale of caste hierarchy. This means that certain persons are forced into cleaning other people’s excreta and garbage because they are “ritually impure”. This creates perverse incentives for everyone else in the system to stay far away from working towards maintaining private or public cleanliness because any such attempt might impact one’s ritual position in the caste hierarchy. This results in a free fall towards filth and garbage thrown all across without affecting anyone’s feelings of cleanliness or aesthetics because eventually what matters is the ritual purity of the private space. In this process, public and civic sense itself is stigmatised and discouraged. Unsurprisingly, India is perhaps the filthiest country in the world, despite growing at a faster pace than many other poorer countries.
The above implications serve to explain the lack of public sanitation in India by highlighting two features. While the notion of private ritual purity is paramount to the casteist mind, anyone who engages in sanitation activities is automatically deemed to be ritually impure. To summarise the entire argument, let us take the example of manual scavenging, of which India perhaps remains the only practitioner in the world. For the typical urban/rural Indian, mechanisation of sanitation work is not a concern at all because in the casteist imagination certain social groups are destined to forever engage in such work.
With regard to the second lesson of public solidarity, there are two socio-structural aspects that impair its emergence in India, namely caste and neoliberalism. The caste principles of purity and pollution actually blind a person to the point that he/she is utterly indifferent to
questions of public hygiene and sanitation. But even more crucially, caste is the very antithesis of any form of life based on association with other human beings. According to B.R. Ambedkar, every caste in the entire caste system exists in social isolation from another caste. This means that not only are they inward-looking in every sense but they are single-mindedly focussed on their own interest. A democratic society requires that different social groups interact freely and arrive at certain common political goals on the basis of shared interests. As is obvious, a caste society cannot be democratic because it lacks a central element which can be variously described as public spirit or civility.
Such isolation and separation of interests among distinct social groups may arguably be a feature of every multi-ethnic society. However, it is the added characteristic of hierarchy between castes and varnas that narrows the possibility of any kind of exchange of experiences and creation of common sentiment across castes. Ambedkar asserts that the caste system and untouchability are also a form of social psychology based on “social nausea”, whereby groups exhibit active hostility towards one other. The perpetuation of castes thus militates against the very notion of a “public” realm, which lies at the very basis of public action based on a common agenda.
But we know that in modern democratic societies, public systems do get created. Whether those public systems attain good quality and universal reach is a matter of how different social groups in society view the operation of those public systems (of health, education, transportation, water supply, and so on).
In Indian society, populated by a grand multitude of castes, restricting access to good quality public systems is a form of exercise of social control over subordinate castes. We know that in under-developed agrarian contexts such as in Bihar, Jharkhand and Telangana, this takes the form of control over who gets to work/paid under Mahatma Gandhi National Rural Employment Guarantee Act 2005, or who gets the licence to run public distribution systems to control access to food. Dominant castes exercise such control to demonstrate their dominance over the social life and labour of the oppressed castes by gatekeeping access to these public facilities. At the macro (national or State) levels, poor sanitation, air quality, water supply, etc., obviously create a plethora of health problems that impact everyone. Rather than investing in public health, the Indian elite has encouraged the mushrooming of water and air purifiers in the market, and the promotion of unregulated private clinics. In the post-1990s neoliberal phase, the Brahminical elite has aided the weakening of public systems and the creation of a parallel private universe where basic public services are provided for a premium (in terms of both caste and class). But the limitation of this private health care system is that it has no space for the classical public health concerns, made apparent by COVID-19.
Thus, casteist notions of health and sanitation prevent society and the state from organising and implementing basic public health interventions in India.
Remember that such interventions are inexpensive for policy and extremely beneficial for the overall welfare of the population. The desire for social control, a feature of the Brahminical elite, overpowers any concern for economic growth or national development that may, in turn, also benefit the elite themselves. This is evident from various studies which demonstrate that the most common cause of rapid decline in the social and economic status of families is health crisis.
NEOLIBERAL CAPITALISM
These limitations of the caste society and the ideological backwardness of the Indian elite are compounded by the overall dominance of neoliberal economics in academics and neoliberalism in government and policy advisory circles. Many social science students, especially those trained in neoliberal economics, who go on to occupy important positions later consider the provision of health care services and education by the government as a result of market failures—situations where markets fail to provide certain goods and services even when they function efficiently. In themselves, health care and education are considered purely private goods in economics. The emergence of public health as a category is rarely historicised in economics classrooms; there is no comparative framework either.
The political philosophy behind neoliberalism is simply called libertarianism. Libertarians believe in a kind of negative freedom, that is, the absence of any external coercion. The term free market is a good illustration of this idea—markets freed from what? The answer, according to the libertarians, is state control. In this framework, personal liberty is always supreme and common good is more often than not considered illusory. It is the duty of individuals to make good and informed decisions regarding their life, including health. If a smoker decides to buy a health insurance product, a higher premium reflects his poor choices in the past and in a way provides him with an “incentive” to quit smoking.
Even during the COVID-19 pandemic, the solution, according to the libertarians, is insulation rather than social solidarity. Please note that a forced lockdown by the state is against the very grain of libertarian thinking. It is partly the rapidly infectious nature of COVID-19 and partly the fear of social solidarity that causes libertarians to readily sacrifice personal liberty in their fight against the pandemic. In fact, come to think of it, social distancing as a phrase is itself libertarian in nature, calling out to all individuals to save themselves, warning them that if they do not, they will be held responsible for their own health care needs.
The other concern that the libertarian philosophy has with the state is of efficiency and corruption. The solution to the problems of corruption and unaccountability in public systems is the separation of the two functions that the state undertakes while provisioning, say for example, health and education.
These twin functions are purchasing and provisioning. The state purchases health care from doctors, nurses
and other health professionals and at the same time provides health care to the people in the public hospital. In such cases, no one can be held accountable for any ill-functioning in the hospital because the purchaser and the provider of the service, that is, health care, is the same entity—the state. A split between the purchaser–provider function will ensure competition and choice for the “customers of health care”: the insurance company for instance buys health care on behalf of the consumer from a variety of providers. The consumer of health care can go to any health care provider and because there is a competition between the providers, they are on their toes to maintain high levels of service. Similar prescriptions are made in the field of education with what is called school coupons. Students can be given school coupons that they can utilise in any school of their choice.
There are a lot of problems with the insurance model, most importantly that the out-of-pocket expenditure continues to be high even after high premium payments. However, the major problem in this framework of health is that it is restricted to the individualised understanding of health care and it is impossible to imagine a common political goal based on shared interest towards a public health system. So, it is difficult, nay impossible, for a neoliberal economist to appreciate the category of public health. Indeed, neoliberal economics is constructed in such a way that it simply defines away the notion of public health. As is the case with almost all capitalist democracies in the world, there is always pressure from electoral politics, and sometimes concessions simply have to be made. No wonder, then, that in the sphere of policymaking, we have been witnessing a strange combination of neoliberalism-inspired government-subsidised health insurance models (as in the case of the Rajiv Gandhi Swasthya Bima Yojana or, more recently, Ayushman Bharat) working hand in hand with publicly funded strengthening of the health system (as in the case of the National Health Mission). According to the former Union Health Secretary K. Sujata Rao, between 2007 and 2014, India worked with a “dual policy” arrangement. There was an overall injection of Rs.200 billion a year (including public expenditure plus private, tax-exempted out of pocket personal spending) into the private sector via health insurance premiums, which allowed it to capture the secondary and tertiary health sectors.
During the same period, a similar amount of money was spent every year on the National Rural Health Mission
in order to strengthen the primary health care segment.
In the time of COVID-19, it is increasingly realised that a universal and well-functioning public health system is the need of the hour. The draft (third) National Health Policy of 2015 had declared its commitment towards health care as a fundamental right. However, the final NHP of 2017 crops this promise thus: “a progressively incremental assurance-based approach, with assured funding to create an enabling environment for realising health care as a right in the future”.
The public health discourse in India continues to be deliberately confused between two polar positions: first, a welfare-state orientation based on a universal public health system that requires heavy investments in the creation of public health infrastructure such as in NHM; and second, a neoliberal orientation that requires public investment in the private health insurance system. As pointed out earlier, this confusion is deliberate because of the Brahminical elite’s desire for social control and neoliberalism’s insistence on fiscal control and withdrawal of the state. The Brahminical elite and neoliberal state have created a new system of health apartheid whereby the public health system has been marginalised, starved of resources and kept reserved for the poor whereas the best of private health care is available for the rich, national and international.
In conclusion, the public health agenda in India has two components: a struggle for social justice against caste, and the fight against neoliberal social policy. At the socio-political level, the inclusion of health in the social justice agenda will create public interest and a shared concern that will be the first step towards a sustainable public health system in India. A public health, education or transport system creates stakes for all sections of the population in its functioning and sustenance. The feeling of being part of a common/shared concern can be a way towards breaking social and cultural barriers between castes and classes. In this way, public systems are political weapons against segregation in society and polity.m
Awanish Kumar teaches in a college in Mumbai.
Bibliography and Further Readings
Birn, Anne-emanuelle, Pillay, Yogan, and Timothy H. Holtz (2017). Textbook of Global Health. New York: Oxford University Press.
Coggon, John (2012). What Makes Health Public: A Critical Evaluation of Moral, Legal, and Political Claims in Public Health. Cambridge: Cambridge University Press.
Hart, Julian Tudor (2010). The Political Economy of Health Care: Where the NHS came from and where it could lead. Bristol: The Policy Press.
Kethineni, Veeranarayana (1991). “Political Economy of State Intervention in Health Care”. Economic and Political Weekly, Vol 26, No 42, October 19, pp. 24272433. Panitch, Leo and Leys, Colin (2009). Morbid Symptoms: Health Under Capitalism. Socialist
Register. New Delhi: Leftword Books.
In the new system of health apartheid, the public health system is marginalised while the best of private health care is available for the rich.