The Wall of Caste— A Study Exposing Discrimination Against Dalits in South Asian Healthcare Highlights Why India’s Caste Census is Crucial!

New Delhi- As India prepares for its much-anticipated caste census, it would be relevant to discuss a groundbreaking study that exposes the deep-seated discrimination faced by Dalit communities in accessing healthcare across South Asia.

Published on May 24, 2021, in the Asia Pacific Journal of Public Health, this research by Raksha Thapa, Edwin van Teijlingen, Pramod Raj Regmi, and Vanessa Heaslip analyzes nine studies to reveal how caste-based inequities, compounded by poverty and cultural barriers, systematically deny Dalits, historically labeled as “untouchables”—their right to healthcare. A large number of Dalits in rural areas in India are deprived from or are refused access to health services due to their social status.

Typical discriminatory behaviors include refusing to enter Dalits’ houses or allowing them into your house, share food and water, seating places, transport, and generally refusing to touch. Health discrimination is likely to be seen mainly in areas where care is provided, which can be health centers or a patient’s own home.

The findings highlight a harsh reality: despite legal efforts to dismantle caste hierarchies, discriminatory practices persist, severely impacting Dalit health and well-being. This study strengthens the case for India’s caste census, which could be a vital step toward understanding and addressing these inequalities.

The Burden of Caste: Dalits Excluded from Healthcare

The caste system, a 3,000-year-old social structure rooted in Hindu tradition, continues to fuel social, economic, and health disparities in South Asia. Despite being outlawed in India and Nepal, caste-based discrimination remains entrenched, particularly in healthcare. This study, which reviewed research conducted between 2000 and 2019 in India (seven studies) and Nepal (two studies), identifies four key themes: social stigma, poverty, cultural beliefs, and access to healthcare. These themes highlight the complex barriers Dalits, especially women, face, which undermine their health and dignity.

Key Findings of the Study

Socioeconomic Disparities and Poor Health Outcomes:

• The study found that low socioeconomic status and limited land ownership are directly linked to poor health outcomes for Dalits. With restricted access to education and well-paying jobs, Dalits often have low household incomes. Social discrimination and poverty confine them to low-status jobs, denying them equal opportunities in the labor market.

• In Bihar, India’s poorest state, local public medical services, often the only services affordable for Dalits, only addressed basic health needs. Despite developments in the Indian health structure including availability of subcenters, public health centers, and community health centers, poorer communities still experience a shortage of health institutions and skilled health workers.

Double Discrimination Against Dalit Women:

• Dalit women face a dual burden due to their low caste status and the lower status of women in Hindu society. They endure increased risks of domestic violence, severe illnesses, and limited access to treatment beyond local facilities. For instance, Dalit women use antenatal care (ANC) services far less than higher-caste women, leading to worse maternal and child health outcomes. While wealthier Dalit households show slightly better ANC usage, the combination of low caste and poverty consistently results in poorer health outcomes.

Cultural and Social Barriers:

• Cultural beliefs deepen health inequities. Many communities view Dalits as incapable of understanding health information, leading healthcare providers to withhold critical guidance. In some areas, illnesses are attributed to supernatural causes like spirit possession, causing Dalits to rely on traditional healers rather than modern medicine, further limiting their access to proper care.

Discrimination in Healthcare Access:

• All nine studies confirm that caste directly impacts healthcare access. In Uttar Pradesh, only 19% of Dalits with chronic illnesses receive treatment due to high costs, long travel distances, and untrained providers. In Nepal, weak healthcare infrastructure disproportionately affects Dalits, who struggle with paperwork and accessing free services. Dalit healthcare workers, such as auxiliary nurse midwives, also face disrespect from colleagues and patients, undermining their ability to provide care.

Poverty and Stigma: The Dalit Dilemma

Poverty is a major barrier to healthcare for Dalits. Most live below the poverty line, relying on low-paying jobs like manual labor or basket weaving. They often lack awareness of free healthcare services or government schemes, and unlicensed practitioners frequently exploit them with exorbitant fees. Taking loans to cover medical costs is common, trapping families in a cycle of debt. Social stigma further compounds their struggles—healthcare providers often refuse to touch Dalit patients, and mental health issues are misattributed to supernatural causes, limiting access to modern treatment.

Dalit Women: The Most Vulnerable

Dalit women are the hardest hit by this discrimination. Their low caste and gender expose them to higher risks of malnutrition, anemia, and maternal mortality. The study notes that nearly 70% of Dalit women are illiterate, limiting their health literacy and ability to navigate healthcare systems. Economic dependence on men, restricted mobility, and domestic violence further hinder their access to care.

Dalit women usually do not visit hospital for treatment due to the travel distance to the hospital and they cannot afford travel expenses or high treatment fees.

The study emphasizes that caste-based discrimination is not just a social issue but a public health crisis. Despite Nepal’s 1962 ban on caste discrimination and India’s affirmative action policies, implementation gaps and entrenched cultural attitudes sustain inequalities. The authors argue that improving healthcare requires addressing sociocultural factors like stigma and gender inequality. Programs like self-help groups (SHGs) and ANC have helped, but they fall short without broader societal change. The study calls for caste to be included in global policy discussions, such as the Sustainable Development Goals (SDGs), to achieve targets like poverty reduction, good health, quality education, gender equality, and reduced inequality.