Medico Friends Circle

Background Paper for the 2023 Annual Meet¹

Introduction

The Annual Meeting of the Medico Friend Circle held on 26-27 March 2021 decided the theme for the coming year as “Institutional hierarchies and discrimination in the health system on the basis of caste, class, gender and minority religious identities.” For this an organising committee (OC) was constituted who have drafted this Background Note, which sets out various ways in which the theme can be effectively discussed in the Annual Meet of 2023. It is an attempt to provide some background on various aspects and raise questions for deliberation; as a first draft it is meant to be a starting point for debate and discussion at the MFC Mid Annual Meet on 15-17 July, 2022 in Bengaluru.

History of MFC’s engagement

Way back in 2013-2014, the Medico Friend Circle had brought the focus on social discrimination in health and discrimination as a determinant of ill-health (MFC Bulletin #357-360). The 40^th Annual Meet was around the theme of social discrimination in health with reference to caste, class, gender and religious minorities. The issues remain as relevant as ever as we continue to study the various dimensions operating in the current political and social context, towards understanding institutionalised discrimination.

The 2014 Annual Meet Concept Note highlighted how socio-economic inequalities lead to unequal and adverse health outcomes, and concluded:

‘A rigorous understanding and study on discrimination and health require conceptual clarity about the exploitative and oppressive realities of caste, class, gender and other multiple forms of adverse discrimination. It also requires careful attention to domains, pathways, level, and spatiotemporal scale, in politico-historical context; besides, structural level and individual-level measures to gauge without relying solely on self-reported data or the bureaucratic reports. An embodied or grounded analytic approach would help better understand and analyze realities of discrimination.’

(E. Premdas Pinto and Manisha Gupte, MFC Bulletin 357-360, 2014)

The extent of grounded research on these issues produced and published since then by MFC remains to be assessed. MFC’s selection of the topic of institutionalized discrimination has been pending for the last couple of years with cancellation of annual meets owing to the pandemic. However, we could not have had a more tangible manifestation of the significance of this conclusion that than the fallout of Covid-19 pandemic that ravaged the country since January 2020. Reflecting on how the pandemic affected different social groups very differently and led to extremely disparate outcomes, we feel this discussion on institutional hierarchies and discrimination on the basis of caste, tribe, gender and minority religious identities is both timely and relevant.

Although activists from the concerned movements have been building critique and resistance for decades, the analysis has almost never informed the discourse or practice of health activists and scholars who remain restricted to class and more recently gender, but that too in the binary sense of women and men. The issue has become even more relevant for our times with an increasing culture of impunity around outright discrimination and even violence. Within these very marginalized communities we see sections being co-opted into the dominant discourse and becoming complicit in the erasure of diversity. These emerging nuances and new understandings and ramifications need to inform the discourse of civil society engaged with various aspects of health, including health discourse, health activism, health systems both public and private, health related education, social determinants of health and so forth.

Using this opportunity, MFC could also actively invite friends and fellow travellers from Dalit /Bahujan/ Adivasi/religious minority backgrounds to attend the meetings in larger numbers and work with them to co-create MFC as a space that is more inclusive.

Context –

An endemic problem in the health sector is how health-seeking behaviour of those from socially marginalized communities is critically shaped by adverse experiences with the public health system² where providers often display culturally incompetent and downright biased behaviour that underlines the power asymmetry³. While researching access to healthcare for various communities, the emphasis is usually on the affordability question or at the most, disrespectful behaviour towards poorer patients. What typically gets missed out is the differentiated treatment provided to patients from lower castes or tribes or those from religious or sexual minorities.

Yet most health research and interventions appear to be based on the assumption that ‘health’ or ‘healthcare’ is about an unmarked human being whose existence is unaffected by contours of privilege or powerlessness⁴. The recent case of Payal Tadvi, a tribal Muslim doctor who committed suicide after severe caste-based harassment within a medical institution⁵ was a wake-up call. Yet it is only the latest instance of a long history of invisible persecution faced by those from disadvantaged social groups and is just the tip of the iceberg.

Gender, caste and community have traditionally been linked with specific occupations, including in the health sector. Occupational hazards in India are generally neglected but these could be worsened by exploitative conditions and lack of attention to health risks in jobs based on one’s caste, class, gender, religious location and so forth, as starkly shown by social caste-based location of Class IV /Group D staff and sanitation or sewage workers. Going beyond healthcare to examining the social dimensions of food and nutrition, we find social biases shaping policies and practices around acceptable foods. These have taken an extreme form in recent years as attacks proliferate on those suspected of serving, storing or transporting different kinds of meat, with perpetrators often enjoying complete impunity.

The COVID-19 pandemic and the impact it had on different sections of society provides us with a stark reminder of how institutional discrimination and hierarchy operate⁶. The term ‘social distancing’ itself was a cruel reminder of how caste, community and class divides were enforced while social biases grew increasingly rigid⁷. Policy making was shaped by the experiences of the privileged who could afford to ‘work from home’ while the vast majority of the poor from socially marginalized communities were devastated by loss of livelihoods, shelter and lives. The lack of protective equipment for those most exposed such as the frontline health workers, ASHA workers, Class 4 staff in health institutions, mortuary and crematorium workers, sewage and sanitation workers was a reflection of their gender, caste and class locations⁸.

Since MFC itself functions as an informal institution, this is an opportune moment for internal reflection within MFC individually and collectively on what has been the extent of diversity within MFC at all levels, including convenors, editors, organizing committee members and the areas of research. As a collective that is about to celebrate the remarkable fact of its 50^th year of continued existence, MFC is well placed to internally assess its inclusivity in terms of thematic focus, representation, affirmative action and current diversity.

Current debates about these concepts have raised questions that interrogate the schism between intention and practice, seeking to assess whether efforts at diversity indicate tokenism or actually follow affirmative action in practice and spirit to co-create inclusive spaces. The extent of efforts made to reach out to and include people based on caste, gender, class, religion, geography need review, especially to engage substantively with Ambedkarite, Phuleite, Periyarist, transgender and Adivasi scholars who have worked on health. Most recently a vigorous discussion took place on the MFC e-group in March 2022, under the subject ‘Caste and mfc’, in which a number of people participated and debated to what extent MFC had addressed the elephant in the room.

Suggested domains

Given below are some of the key aspects of the issue of institutional discrimination that were seen as important to bring to the discussion. We hope these will stimulate MFC members and those from other movements to contribute articles and papers looking at discrimination based on caste, tribe and religion as well as against non-binary gender identities. We encourage those writing papers to keep the recent COVID 19 experience in mind during their analysis.

I. Provision of health care and delivery of healthcare services as well as User experiences of discrimination: How does discrimination manifest within the healthcare system to impact those who are approaching health institutions?

How does discrimination manifest itself in the development of policies, in the utilization of resources, in decision-making and staffing patterns within the health systems?
What are the caste, gender and religious prejudices that operate to keep this discrimination on-going? How do these operate to reduce availability, access (also affordability) and quality of services? What about the medical community’s attitude towards transgender and intersex persons?
What are the checks and balances that need to be in place to address these inequities?
What is the interplay of health outcomes with social determinants of health and what role can the health system play to minimize the adverse effects and outcomes?
How does the digital divide disadvantage the particular social groups?
What is the attention to mental health needs of those from disadvantaged communities, including those facing stigma and discrimination, those in conflict and post-conflict settings and others?

II. Occupational hazards and the health workforce (including doctors, nurses, dais, ASHAs, sanitation, mortuary and conservancy workers, contractual staff and newer home-based cadres)

How do we link caste-based occupations such as TBAs as well as sweepers, masseurs (and others who handle bodily fluids) to what is the gaze of the health system towards them?
What are the groups most vulnerable to occupational hazard exposure, specifically in the context of the health system?
How do marginalized identities compel certain groups into specific occupations and what occupational hazards do they face? (for example, transgender sex workers and sexually transmitted infections)
Are there adequate mechanisms to prevent, diagnose, treat and/or monitor workplace related accidents and occupational hazards?
Are there enough reimbursement mechanisms for occupational related health care Mortality and morbidity?
What is the current status of functioning of the Employee’s State Insurance Scheme (ESIC)

V. Educational system including the public and private sector – medical/nursing/other cadres education, NEET and other issues (curricula & textbooks etc)

What are the mechanisms by which caste and other axes of discrimination work in institutions – especially meritocracy / discrimination and so forth?

How are these various mechanisms embedded in institutional structures and logics? And how does this impact on those who are working in these institutions?
How are these discriminatory mechanisms and institutional logics / design / structures – reproduced by the silence / blindness of those who hold power – including civil society that is caste/ communal/ gender blind (or even caste/minority/trans oppressive, with active discrimination being practiced even in so-called activist organizations)?
How does reservation work out in reality within the healthcare system?
How does discrimination manifest within the healthcare system in general – including the design of multiple health systems for different categories of people within the same country?
How does discrimination manifest within medical education⁹ in particular? This is not just doctors but also other medical institutions and medical policy-making positions
What about medical research and drug trials – who are recruited as subjects and from where? Which social groups do they belong to? What makes them agree?

VI. Social Determinants – Food and nutrition, livelihoods, gender-based violence, etc

How do we see the notions of caste purity and ritual pollution in the criminalization of meat eaters and the impunity accorded to those engaged in violent enforcements of such norms?
How does current policy making across different sectors promote and encourage vegetarianism from a particular religious and caste standpoint?
How is the nutritional level of marginalized populations affected by the current policy and political climate?
How does the health system address the needs of those who have faced violence, including those who have faced violence at the hands of state actors?

VII. COVID 19 pandemic management and impacts:

What are the various kinds of discrimination that have become more evident during and following the Covid-19 pandemic?
How did the pandemic affect the working conditions of ASHAs and hospital, mortuary and sanitation workers?
How has the system responded to address or worsen these various inequities? What if any were the grievance redress mechanisms or space for representation available?
What influences crucial decision making in the country and how has this manifested during the Covid-19 pandemic?

VIII. Discrimination and health organizations – How do larger health related networks/movements and organizations (including MFC) address these issues – representation, programmatic attention and internal dynamics and relationships. how MFC can improve its own approach to these issues internally & work on these issues, given the current socio-political situation in the country –

How does the current political and social situation in the country aggravate or create different forms of discrimination? What are the systems that could be put in place to challenge state sponsored discrimination?

How did we respond to post-riot situation of Muslims? What about mental health issues of these women, or of Muslims in Kashmir?
What is the specific role envisaged for platforms such as the MFC in the current political milieu? How do we “do” anti-caste work? Can we turn the lens on to ourselves as research subjects? How can we avoid stonewalling using the Class and Gender arguments?
How do we start anti-caste conversations? How do we avoid the issue of ‘othering’ in discussions focused on the oppressed rather than the oppressor communities?
How do we transcend the identification of “victims” to the recognition of “agency”?

We hope these provide some food for thought and encourage wide-ranging debate, not only towards generating ideas and inspiration for papers and sessions in our Annual Meet in 2023 but also in creatively rebuilding MFC to be a more genuinely inclusive space.

Guidelines for contributions: last date 3 January 2023 – send to mfcbulletin381@gmail.com

Contributions can be as papers, articles, videos, songs and poetry. They can include stories of resilience and resistance as well as experiences and testimonies
The contributions can be up to 1500 words; references can be written as endnotes
All abbreviations must be given in full form the first time they are used in the paper or article
Jargon used by specialists can be avoided as the Bulletins are for general readers
Already published papers can be shared as background or reference documents for the MFC members and participants.
Papers that are selected for the Bulletin will be published before the Annual Meet; videos will be uploaded on MFC website
However, contributors are not meant to present their own papers, they are presented and discussed by others.

1 Drafted by Jashodhara Dasgupta and Sylvia Karpagam on behalf of the Org Committee that includes Bijoya Roy, Mithun Som, Nidhin J., Prabir Chatterjee, Priyadarsh Ture, Rakhal Gaitonde, Sanjay Dabhade and Savithri D. The draft was revised based on comments given by the participants of the MFC Mid-Annual Meet on 16-17 July 2022.

2 Ravindran S, Gaitonde R, Srinivas PN, Subramaniam S, Chidambaram P, Chitra G. Health Equity Research: A political project. In: Health inequities in India: a synthesis of recent evidence. Singapore: Springer; 2018

3 Sana Q. Contractor, Abhijit Das, Jashodhara Dasgupta and Sara Van Belle (2018) Beyond the template: the needs of tribal women and their experiences with maternity services in Odisha, IndiaInternational Journal for Equity in Health 17:134

4 Awanish Kumar Caste and Public Health Cover Story Frontline May 22, 2020

5 She was a 2nd year post-graduate in Gynaecology and Obstetrics and resident doctor in the Brihanmumbai Municipal Corporation’s BYL Nair Hospital, who committed suicide in May 2019. Reported in The Steady Drumbeat of Institutional Casteism: Recognise Respond Redress by Forum Against Oppression of Women, Forum for Medical Ethics Society, Medico Friend Circle and Peoples’ Union of Civil Liberties, Maharashtra, September 2021

6 Vatya Raina, Ananya The Lockdown in India- Understanding the matrix of caste, class and gender Commentary Economic and Political Weekly 56:8, Feb 2021

7 Suraj Yengde What makes injustice to migrant workers more acute is the fact that many of them are

Dalits (Indian Express 5 April 2020) https://indianexpress.com/article/opinion/columns/dalitality-the-caste-factor-in-social-distancing-coronavirus-6347623/

8 PHM Health Systems Thematic Circle and Alba Llop-Girones, Ana Vracar, Ben Eder, Deepika Joshi, Jashodhara Dasgupta, Lauren Paremoer, Sulakshana Nandi, Susana Barria (2021) A Political Economy Analysis of the Impact of Covid-19 Pandemic on Health Workers: Making power and gender visible in the work of providing care Yale Law School Global Health Justice Partnership Comment July 2021

9 Feel depressed because they are facing harassment and discrimination; but are too reluctant to voice their issues, or may just choose suicide because their complaints will never be heeded. There are laws on Ragging and on SC/ST atrocities but a gap in-between, maybe there is need for something like the POSH Act

Medico Friends Circle

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Caste, tribe and religion: Institutionalized discrimination in health

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