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Gujarat, Rajasthan: Huge discrimination in delivery of healthcare services to Dalits

By Rajiv Shah 
Is discrimination of Dalits in the delivery of basic services an international human rights issue which needs a much deeper exposure than has been the case so far? The question is significant, because, despite lobbying at various levels on the part of the International Dalit Solidarity Network (IDSN) during recent years, the Government of India has strongly refused to acknowledge caste discrimination as an international human rights issue, which should be dealt with in the UN. Whether it is water, sanitation or health, the discrimination continues, and government sops have failed to do anything to subdue its impact. A recent www.counterview.org report (click HERE to see it) highlighted how discrimination in the provision of water in the Indian state of Gujarat has meant untold hardships to Dalit women, who cannot access water from the common source in Ahmedabad’s rural areas.
This is quite in line with what a UN expert who visited India in 2012. In her annual report, the Special Rapporteur on the human right to safe drinking water and sanitation, Catarina de Albuquerque, studied the links between stigma and discrimination in the realization of the right to water and sanitation. She found that “caste systems are striking examples of systems that lead to the stigmatization of large parts of the population, potentially amounting to violations of human rights”, and that “in terms of water and sanitation provision, Dalit habitations are often systematically excluded”. While there is paucity of studies on how discrimination prevails in the delivery of service, at least two recent studies have highlighted this factor, basing their facts on primary surveys.
The studies are – by Sanghamitra S Acharya, assistant professor at the Jawaharlal Nehru University, and carried out for UNICEF and Indian Institute of Dalit Studies, Delhi, and jointly by the East-West Management Institute and the Navsarjan Trust, Ahmedabad. These have highlighted, perhaps for the first time, how “access to civic amenities and social facilities” related to health remains an issue of “concern in the context of the Dalits.” Acharya’s study, “Access to Health Care and Patterns of Discrimination: A Study of Dalit Children in Selected villages of Gujarat and Rajasthan” (2010), states, “Although the constitutional provisions have been in place for penalising those practising discrimination, yet it continues to thrive. Discrimination against Dalits has metamorphosed over time from overt, open and accepted norm to subtle, invisible, hidden and ‘unaccepted’ behaviour.”
Acharya’s study looks at the nature and forms of discrimination experienced by Dalit children in accessing health services provided by the primary health centres and private sector providers in the rural areas. Employing a blend of public health and social exclusion approaches, it measures the degree of discrimination in healthcare for Dalit children in various spheres. It argues that the consequences of discriminatory practices severely limit Dalit children from accessing health services, and are attributable to the poor health and high level of mortality of Dalit children in the studied areas. Highlighting inabilities of the present policy frameworks to deal with caste and untouchability based discrimination in health care services, the study calls for developing safeguards and codes to check discriminatory practices at all stages of service delivery.
The study is based on the study of 12 selected villages in two states of Gujarat and Rajasthan. Ahmedabad in Gujarat and Barmer in Rajasthan were the two districts selected for primary survey. The villages were selected from Dholka taluka in Ahmedabad District and Barmer tehsil in Barmer District. Two hundred Dalit and 65 non-Dalit children were interviewed from the 12 selected villages. In case of those aged below 12 years, their mothers were interviewed. The respondents were mothers, children, Panchayat Raj Institution (PRI) members, non-government organization (NGO)/ government organization (GO)/ self help groups (SHG) workers; Anganwadi workers; auxiliary nurse midwife (ANM) and health worker (HW). A couple of group discussions and consultative meetings were also held in each of the village. As many as 15 variables of discrimination in different spheres, forms and providers were selected. The recall period was one year prior to the field work. These included visits to the doctor (diagnostic), conduct of pathological test, counseling, dispensing of medicine, seeking referral (spheres); duration of interaction with the care provider, touch (without offending), speak gently, no use of demeaning words/phrase, not waiting to give chance to the dominant caste person(s) (forms); and different care providers such as doctor, lab technician, pharmacist, auxiliary nurse midwife (ANM), health worker.
The study’s findings are quite revealing: “Most children experienced caste-based discrimination in dispensing of medicine (91%) followed by the conduct of the pathological test (87%). 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. As regards the discrimination by providers such as doctors, lab technicians, ANMs/ VHWs/LHVs, and AWWs, the grassroots level workers like ANMs and AWWs were the most discriminating than higher order providers such as doctors.”
Polio vaccine
The study says, “More than 93% times dalit children have experienced discrimination at their hands while about 59% 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% times) and least in the conduct of the pathological test (71% times).” It adds, “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. They need to position a Dalit child’s body part for an x-ray, or a blood test, for instance, as much as they do for the others. So this form of discrimination is ‘less’ practiced by them.”
As regards the ANMs, the study says, “more than half of the total visits that they have made to the Dalit households, it has been after they have visited the others. Almost every time they have visited Dalit households, they have not entered the house and have taken great care not to touch their children and have spent lesser time than they usually would have spend with the non-Dalit children. Almost always (98% times), the AWWs serve food to the Dalit children at the end. The traditional Healers and RMPs appear to be less discriminating than other providers. However, non- Dalit Providers often contend that they do not differentiate while offering the services, when they actually do. They talk to the Dalit users in haste; and do not speak respectfully/ lovingly (with children). Dalit users always feel inhibited to ask anything related to their health. They feel they will be snubbed or ridiculed, or not attended to. They are often not told properly about which medicine to take and how.”
Other forms of discrimination include “dispensing of medicine, not being touched by the pharmacists and the ANMs while dispensing the medicine; waiting for lab technicians (LTs); ANMs not entering the house and spending less time; and anganwadi workers (AWWs) serving the food to them towards the end.” It adds, “Doctors during diagnosis are sometimes less probing regarding the health problem, have an unsympathetic attitude and rude behavior towards the Dalit children. The pharmacist while dispensing of medicine, often keep on the window sill without explaining the doses properly. The LTs do not touch during the conduct of a test, they use of demeaning words, tests are often not conducted properly. They are told that the time to conduct the test is over. Nurses while applying medicine or putting the bandage on to a Dalit user, reflect lack of any concern or sympathy. They do not explain to the Dalits how to take care of the wound/dressing.”
Field visits by the author reveal that in Ambaliyara village of Dholka taluka in Ahmedabad district, “children from the Dalit community are seated separately from those belonging to upper castes in the anganwadi centre. In most villages there are separate aganwadis for the Dalits and the non-Dalit children. In the Aganwadis where children from both communities come, separate vessels are provided for drinking water.” The author reveals how 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 centers/ hospitals in other places at time of emergency, free of cost. 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 incase of emergency.”
In another village in Dholka taluka, Bhurkhi, “most of the Dalits have to wait longer for their turn because the upper caste people are given priority. In some of the villages, the Dalits are given equal priority in terms of appointment with the doctors as the latter also belongs to the Dalit community. The Dalits drink water from separate vessels kept for them. The ANMs and other health workers rarely visit the dalit quarters of the village.” In a third village, Siyagpura, “Dalits do not sit on the benches available inside the care centre both public and private. In other provisions of public health like water and sanitation, there is rampant caste discrimination. The upper caste people warn the Dalits not to enter into water fetching premise and also ensure that the Dalits do not touch them. They do not accept water touched by the Dalits.”
Dalit children discriminated in polio eradication: The second study, “Blind Spots to the Polio Eradication Endgame: Measuring the Limitations of Polio Vaccination Delivery in Dalit Communities in Gujarat, India”, surveyed in 2011 the families of 2,308 children ages five and under from 77 villages in eight districts in Gujarat – Ahmedabad, Bhavnagar, Gandhinagar, Kheda, Mehsana, Patan, Rajkot and Surendranagar. It found significant numbers of missed Dalit children, as well as dramatic differences in the delivery of immunization services between Dalits and non-Dalits. Its main findings include:
The study comments, “With 25 million Dalit children age 6 and under in India, this study provides evidence that polio vaccination campaigns are missing perhaps millions of Dalit children due to ongoing unlawful untouchability practices in these communities. Dalit communities are of special concern, both for equity reasons (a documented history of discrimination in health services), and because these communities are especially at-risk for transmission of the poliovirus. Unvaccinated Dalit children generally come from communities with less access to proper nutrition and sanitation, creating weakened immune system response to convert the polio vaccine. Moreover, some Dalit sub-castes – the Valmiki in particular, who number 500,000 in Gujarat – have a higher exposure to activities at risk for transmission of the poliovirus due to their traditional work in manual scavenging, including the removal of human feces by hand from dry latrines.”
The study underlines, “Despite government efforts to reform these practices over the years, manual scavenging remains prevalent and some 50,000 Valmikis are employed in the manual removal of human waste in Gujarat alone. Dalits, therefore, are particularly vulnerable for transmission, and, in turn, the herd immunity protecting Dalit communities is more fragile: due to this higher transmission risk, coupled with less effective vaccination programs and monitoring of these programs. In the State of Gujarat this vulnerability is especially noteworthy because Gujarat lies just 100 miles east of Karachi, where Pakistan’s first case of polio for 2013 was reported in January.”
The data from the study “confirmed”, the authors say, that “Dalit children are often missed in polio vaccination campaigns (15.8%), some non-Dalit children are also are missed (6.0%), and Dalits are missed at a rate far exceeding non-Dalit children in neighboring communities. Nnearly one out of six Dalit children went unvaccinated, this rate of missed Dalit children is nearly two and a half times higher than for non-Dalits in geographically comparable communities. Despite the extensive pulse polio campaign in India, this evidence indicates that many children from traditionally marginalized communities living in hard-to-reach areas remain unvaccinated. Although some non-Dalit children are also missed in these remote areas, the very high rate for Dalits raises notice that the endgame of polio eradication is at risk if greater monitoring is not directed at Dalit communities.”
The study further says, “With 25 million Dalit children age 6 and under living in India, a 15.8% rate of missed children could extrapolate nationally into nearly 4 million, a significant roadblock to the goal of polio eradication. The missed vaccination rates for Dalit children present a particularly acute danger because unvaccinated Dalit children generally come from communities with less access to proper nutrition and sanitation, creating weakened immune systm response to convert the polio vaccine, and because some Dalit sub-castes have a higher exposure to activities at risk for transmission of the poliovirus.”
Thus, nearly 50,000 Valmikis are currently employed in the manual removal of human waste by quasi-state agencies in Gujarat alone. “With the overall population of Valmiki in Gujarat at approximately half a million, those actively employed as manual scavengers represent 10% of the total Valmiki population. With the profession dominated by women, it is estimated that there is one actively employed manual scavenger in as many as half the Valmiki families in Gujarat. Because Dalits are particularly vulnerable for transmission, the herd immunity protecting Dalit communities is more fragile: this higher transmission risk, coupled with less effective vaccination programs and monitoring of these programs, makes outbreaks in the Dalit community more likely.”
The study also found that among all caste categories – non-Dalit, OBC and Dalit – girls missed vaccinations at a higher rate than boys in both urban and rural districts. The differences were most significant in non-Dalit and OBC children, although Dalit girls were also missed in vaccinations more often than Dalit boys.” Among ages 3-5 the differences between girls’ and boys’ missed vaccination rates were most significant: 3.1% of non- Dalit boys received ≤ 1 OPV dose, whereas the rate was 5.8% for non- Dalit girls; 2.8% of OBC boys received ≤ 1 OPV dose, while the rate was 7.7% for OBC girls; and 14.4% of Dalit boys went unvaccinated while the rate for girls was 16.4%.”
Pointing out that “there are several possible explanations for the higher rate of missed vaccinations amongst girls”, the study believes, the “plausible explanation is that girls are more likely to be enlisted for assisting their mothers with housework and child care than their male siblings, and this may cause them to be unavailable to attend vaccination days at the polio booths. This explanation is supported by the higher rate of missed vaccinations in older girls (the gender difference was more significant among girls age 3-5 years than girls 2-5 years). While two-year-olds are still too young to perform household chores and child care, making them more likely to attend polio vaccination events, girls who are aged 3-5 are old enough for such home duties and may be overlooked on some pulse polio days.”

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