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UNICEF-sponsored study says untouchability a major factor in health delivery in rural Gujarat, Rajasthan

Sanghamitra Acharya
By Rajiv Shah 
Even as a recent survey report, prepared jointly by the US-based East-West Management Institute, and Navsarjan Trust, a human rights NGO, has found that nearly 20 per cent of Dalit children aged 2-5 in rural Gujarat “miss” the anti-polio dose, thus failing to be immunized, a top study sponsored by the United Nations Children’s Fund (UNICEF), based on on-the-spot inquiry, has found that untouchability is the most important factor in failure in health delivery to Gujarat’s (and Rajasthan’s) Dalit children. Based on primary data and personal interviews, the study, done a couple of years ago, has surprisingly gone largely unnoticed.
The study is titled “Access to Health Care and Patterns of Discrimination: A Study of Dalit Children in Selected Villages of Gujarat and Rajasthan”, by Sanghmitra S. Acharya, associate professor at the Centre of Social Medicine and Community Health, Jawaharlal Nehru, New Delhi. One is tempted to argue that its weakest spot may be the selection of the districts for getting primary data – Ahmedabad in Gujarat and Barmer in Rajasthan. While Ahmedabad is perhaps the most urbanized district of Gujarat, hence here discrimination against Dalits cannot be as sharp as Barmer, which is a remote Rajasthan district bordering Pakistan.
Be that as it may, the study, carried out with the help of the Indian Institute of Dalit Studies, suggests that even in a “forward district” like Ahmedabad, untouchability remains a major factor to be reckoned with, adversely affecting the delivery of health to the Dalits. In all, 12 villages were selected, six each in the two districts. The villages were selected from Dholka taluka of Ahmedabad district and Barmer tehsil of Barmer district. Two primary health centres (PHCs), two villages with sub-centres and two without a sub-centre were selected from each state.
Also, the information collected was comprehensive. In all, 200 and 65 non-Dalit children were interviewed. In case of those aged below 12, their mothers were interviewed. About 6-10 In-depth interviews were held in each village. The respondents were mothers, children, panchayati raj institution members, NGO/ government organization/ self-help groups workers, anganwadi workers (AWWs), auxiliary nurse midwife (ANM), and health worker. At least two group discussions and a couple of consultative meetings were also held in each of the village.
The study finds that “most children experienced caste-based discrimination in dispensing of medicine (91 per cent) followed by the conduct of the pathological test (87 per cent).” It adds, ”Of 1,298 times that the 200 Dalit children were given any medicine, they experienced discrimination on 1,181 occasions. Nearly nine out of 10 times Dalit children experienced discrimination while receiving or getting the medicine or a pathological test conducted. While seeking referral about 63 per cent times Dalit children were discriminated. Also, nearly six in every 10 times Dalit children were discriminated during diagnosis and while seeking referral.”
The author says, “It was observed that most of the discrimination was experienced by Dalit children in the form of ‘touch’ (94 per cent), when they accessed health care. Duration of time spent between the provider and Dalit children was the next most discriminating form. About 81 per cent Dalit children were not given as much time by the providers as other children. The use of derogatory words and waiting at the place of care provisioning were the forms where less discrimination was experienced as compared to duration of interaction and touch. About seven out of 10 times children were discriminated by doctors, lab technicians and registered medical practitioners (RMPs) vis-√†-vis touch. This form was more vigorously practiced by pharmacists, ANMs and AWWs. They did not touch the Dalit children for almost every time they interacted with them.”
“As regards the place of discrimination”, the study underlines, “discrimination occurs while providing and receiving care at home. Providers do not enter, or only up to a certain limit. Comparatively lesser discrimination is evident at care centres. There are no separate places for waiting, but Dalit users feel inhibited to share the same space as the dominant caste. There is no evident difference in time spent. There are, although, some evidences of use of less respectful words – ‘they are dirty so falling ill is natural’. Dispensing of medicine is done directly on hand through a piece of paper, and not in small packets conventionally used for putting the medicines (‘they can digest even stone’).”
The study says, “In more than 93 per cent times Dalit children experienced discrimination at (pharmacists’) hands while about 59 per cent times they experienced any form of discrimination by doctors. Pharmacists discriminated the most while giving the medicine and least in making them wait for their turn. However, lab technicians seem to be most discriminating in terms of making them wait (91 per cent times) and least in the conduct of the pathological test (71 per cent times). While most other providers discriminate mostly when it comes to touching the Dalit child, probably, due to the nature of the work which lab technicians do, ‘touching’ becomes inevitable.”
The author finds that Amaliyara village in Gujarat has the least number of children who experienced any form of discrimination. But even here things are far from rosy. According to her, “In Ambaliyara, children from the Dalit community are seated separately from those belonging to upper castes in the Anganwadi Centre. In the anganwadi, where children from both communities come, separate vessels are provided for drinking water. One Vinubhai and his wife, a nurse, worked to help the malaria affected persons during one of the outbreaks. They owned a vehicle which was used to take patients to care centres/ hospitals in other places at time of emergency, free of cost.”
However, “the upper caste people initially tried to dissuade them from rendering their services to the Dalits. When they did not pay any heed to their intimidation, they were implicated in false charges of corruption. He is now suspended and the villagers do not have any mode of transportation in case of emergency.” In another village, Bhurkhi, also of Gujarat, “most of the Dalits have to wait longer for their turn because the upper caste people are given priority. The Dalits drink water from separate vessels kept for them. The ANMs and other health workers rarely visit the Dalit quarters of the village.”
The author concludes, “Evidences from the field suggest that non-Dalits are governed by age old beliefs and stereotypes to continue practicing discrimination. Consultative meetings and discussions have reflected that the providers do not visit the Dalit quarters by giving reasons such as preference for central location to enable everyone’s access; and that Dalit quarters are further inwards into the village, thus inaccessible to locate them for rendering the services. Dalit providers, on the other hand, cannot enter the house of the non-Dalit users; if they can, then up to the outer courtyard. They have separate cup/glass etc for consuming offered eatables; and have to wash the vessels after consuming which are ‘cleaned’ once again by the owners. Their ‘efficiency’ is almost always doubted.”
She adds, “Dalit children experience social hindrances toward health care access and often have to travel longer than others for accessing service. Discrimination in the delivery of the services is often visible. Children are not given the chance to express explicitly to the care provider in the health care centre. Burden of health care utilization is often not possible for Dalit children to bear. Benefits of the various development programmes which accrue to Dalit children are few. Different forms of discrimination are manifested at the interface of various factors and hence experienced differently by Dalit children.”

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