The concept of ‘social determinants’ of health is defined by the World Health Organisation as “The non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.” This article argues that caste continues to remain one of the crucial societal forces within Indian settings that dictate and shape health outcomes between various caste groups. Despite its importance as a social determinant of health, caste is also one of the most ignored within existing health care policy discourse. The arguments presented here are drawn from the author’s own doctoral research on primary health care in Kerala.
The state of Kerala introduced a slew of health care reforms under the moniker of ‘Aardram’ mission, which loosely translates as ‘gentle’. The reforms were initiated by the government in 2016 and gradually came into implementation by 2018. The mission sought to revamp the existing health care services in the state through revamping of infrastructure, human resources, better timing of services and above all through interventions in ‘social determinants’ of health. These changes were aimed at the larger goal of achieving sustainable development goals and thereby improving the health outcomes for the population. Addressing ‘social determinants’ was therefore one of the core strategies of the mission. A cursory look at the policy document suggests that ‘social determinants’ is one of the most frequently used concepts within the policy. The word ‘Social determinants’ appears 32 times within the whole document which is 140 pages long (Comprehensive Primary Health Care Through Family Health Centres, 2019).
Despite its frequent usage, a closer look at the policy and its narrative on ‘social determinants’ quickly reveals the chinks in its armour. Though the document nowhere defines the concept of social determinants, its implied meaning could be discerned through the ways in which it appears within the document. For instance;
“…as these deal with various social determinants of health like education, safe drinking water, sanitation or safe disposal of waste.”
“The social determinants of health (safe drinking water, environment, cleanliness, sanitation etc) being crucial to the health of a community”
“FHC [Family Health Centres] also include[s] services required for improving the social determinants of health proper housing, safe water supply, sanitation, waste management, means of livelihood and accessible health care services.”
To the untrained eyes, these sentences seem inclusive and may not invite scrutiny, yet they hint at a rather narrow understanding of the concept. These sentences point to the idea that social determinants equal education, safe drinking water, sanitation, proper housing, means of livelihood and access to health services. When interviewed, similar perspectives were also found reflected within the spoken narratives of senior staff who influence policy setting in the State.
“Then there is something we call social determinants of health. So, when we consider the health of society it depends on a lot of non-medical reasons. Like the availability of safe water supply, good sanitary latrines, environmental sanitation and of course nutrition.” (Senior Policymaker, Department of Health, Government of Kerala)
A pertinent question that deserves to be posed is, do these narrow definitions necessarily constitute ‘social determinants’ or just ‘immediate’ or ‘basic’ determinants of health?
Albeit subtle, these narrow distinctions create a world of difference when used within a policy discourse. More so in the context of low-income countries like India where social locations of people like caste and ethnicity determine their living conditions including housing, access to livelihood, education and consequently their health too. This is evident in the case of underprivileged caste groups in India, namely Dalits. To date, Dalits remain one of the most marginalised and vulnerable social groups in India as well as in Kerala. Studies on Dalit land ownership in Kerala suggest that close to 60% of Dalits still live in congested settlements called ‘colonies’. Today these colonies in Kerala are sites of abject poverty with limited or no access to water or sanitation. They are characterised by their high rates of unemployment, low income, and low educational achievements, specifically among Dalit youths. Women from these settlements mostly depend on the subsistence income drawn from employment guarantee schemes or domestic work.
An obvious corollary is that Dalits continue to experience relatively poor health outcomes when compared to non-Dalit communities. This is also reflected through multiple studies from Kerala and across India that suggest poor utilisation of health care and poor health outcomes among Dalits and Adivasis. For example, today a Dalit woman in India lives 15 years less compared to her non-Dalit counterpart. Anaemia is also more prevalent among them, and they show a lower uptake of antenatal care, among others.
So, how do these policy narratives about social determinants make a difference to the Dalits and their health care in Kerala? This could only be discerned by examining whether these narratives capture the links between the caste locations of communities and their access to basic determinants like drinking water, education or sanitation. The answer is that these narratives on social determinants do not in any way capture how social locations of different communities, shape differential and inequitable access to drinking water, sanitation, education or livelihood. First, the policy narrowly defines social determinants as access to the basic livelihood requirements for populations in general. The result is an erroneous vision of ‘social determinants’ equalised with that of access to ‘basic’ requirements like water and sanitation amongst others. Secondly, through such a narrow definition, the policy becomes separated from the larger goals of equity. It does so by being blind to disparities in the distribution of health determinants across social gradients within communities. As a result, the crucial link between caste identities and access to various basic determinants of health is lost.
This is made further evident in the way caste is problematised within the ‘Aardram’ mission policy document. In the whole 140-page document, only once does it mention scheduled castes (SC), in the context of priority areas to be visited by the field health staff. Here too scheduled caste colonies are mentioned among a list of areas that are prone to diseases like correction homes, old age homes, sewage treatment plants, and public toilets amongst others. As a result, the document proposes a rather curious way of perceiving Dalit colonies as mere health and hygiene hazards that require priority visits. Apart from this, nowhere else does the policy attempt to connect the idea of social determinants and the role of caste in shaping differential health outcomes within the state.
Similar neglect of the idea of caste was also observed in the way it appears within the spoken narratives on health by senior health staff in the state.
“Suppose if we have to think of a new health project, never can we think of it from the perspective of caste or any specific sex. Nor can we think of health projects specific to any small community. Normally it becomes a problem after implementation, where some groups will complain that they did not get fair representation. So, ideally, such issues shall never challenge health initiatives.” (District Program Manager, Dept of Health, Government of Kerala)
“When we think of health, there is no difference based on the caste and creed of individuals. Health is above such differences and is purely biological.” (Senior Policymaker, Dept of Health, Government of Kerala)
These narratives tend to consider caste as, either a challenge to new health care programs or from a perspective where health is purely biological. By locating caste as a challenge and by separating health from its societal context(s) it creates an idea of health that is socially blind, inequitable and unfair.
In summary, the social determinants discourse in Kerala is sans the ‘social’. In the context of the WHO definition of ‘social determinants’ of health, caste can be considered a larger societal level force that creates differential access to basic determinants and thereby shapes disparate health outcomes. However, by ignoring caste and narrowing ‘social determinants’ to the idea of basic determinants, these policy discourses in Kerala stand to further widen the health divides between communities. By failing to acknowledge caste, the powerful policy discourses shape an idea of health care that shall be equal to all sections despite the existing social gradients within communities. By doing so these discourses remain deeply unfair and oppressive to the underprivileged and create further marginalisation of Dalit communities in the State.
Comprehensive Primary Health Care Through Family Health Centres (2019). Policy document, Kerala.
Acknowledgment: Anneke Schmider provided valuable editing and other support for this article.