Caste Background of Health Professionals in India

It is well known that there is inequitable distribution of healthcare professionals across social groups, especially for physicians. The census publishes this data every ten years and the NSSO also collects data on occupations (but does not publish disaggregated data listing various health professionals) but a literature search shows that this subject of caste background of health professionals is inadequately researched and discussed. Humanpower statistics published by the Institute for Applied Manpower Research provides information only for those in public services but does not disaggregate by caste. The SC and ST Commissions who should have a keen interest in such a profile too do not collate and provide any data/statistics about SC / ST occupational data. So generally there is very little information about caste and professions/occupations and this lack of information is indeed surprising given that there exists education and job quotas / reservations for the SC and ST, and now also for OBCs and Muslims.

In 2003 the World Health Survey by WHO and IIPS (2006) on Health Systems Performance Assessment provided an excellent profile of the health system in India but failed to record caste. However they classified households into income quintiles and this data shows some interesting patterns of health human resources. Bottom THREE quintiles did not have a single physician whereas the top quintile accounted for 83 percent of all physicians – not unexpected as doctors have a clear class character and generally class and caste go together so we can deduce that most physicians would also be from the upper caste groups. The 2001 census data in the Table below provides the evidence of the caste character of physicians.

With regard to nursing and midwifery too there was some concentration in the top 2 quintiles in the WHO survey – 61 percent of nurses. The bottom two quintiles had only 19 percent nurses. But for the support health staff the contribution of the bottom quintile was as much as 37 percent.

The 2001 census data in the following table gives a snapshot of the caste character of various healthcare professionals and the distribution patterns are not very dissimilar to what we see in the class distribution from the WHS 2003. The last three columns in the table tell the real story for each social group, Scheduled Caste (SC), Scheduled Tribe (ST) and Others. For the health professional groups the variances from the proportion in the population (non-agricultural workers as universe) for each social group is highly negatively skewed for the SCs and STs, the deficits being between 50 and 80 percent, but for the “others” group it is in excess between 10 to 15 percent. As we move down the hierarchy to nurses and paramedics the variances become narrower and one sees a few excess ratios for SC and ST, notably for the category of sanitarians and nursing/midwifery. For the ST the nursing and midwifery categories surprisingly show a huge excess of over 100 percent. Thus despite affirmative action policies the SC and ST have been unable to break the glass ceiling of upper caste control over the health professions, especially physicians of all types.

Further, the “others “ is a very varied group and includes a number of underprivileged categories like OBCs and Muslims. If further disaggregation for this category was available the upper caste domination, similar to upper class (top quintile) would have come out more sharply. Historical evidence from Gazetteers, Indian Medical Service Reports and writings on colonial medicine suggest that the Brahmins, Parsis and Christians were the first to take advantage of modern medical education and hence they got a head start. Their domination continued in early Independent India but soon other upper caste Hindus, initially Kshatriyas and later baniyas entered the medical profession in large numbers. With reservations for dalits and adivasis they too got an opportunity to enter medical schools. As medicine got commodified, especially post 1980s, and private medical education and

Table 1: Caste Profile of Health Professionals and paramedics for all non-agricultural workforce 2001 Census India Economic Tables B-25, B-25SC and B-25ST           

	Category of Worker	ALL	Caste  Category			Variance from Population proportion*
Occup. Code	A. Health Professionals	Persons	%SC	%ST	%Other	SC	ST	Others
2220	Health Professionals (except nursing)	947433	7.49	1.87	90.63	-42.65	-53.20	9.29
2221	Physicians and Surgeons, Allopathic	617619	7.49	1.50	91.01	-42.68	-62.46	9.74
2222	Physicians and Surgeons, Ayurvedic	107346	5.49	1.23	93.28	-58.01	-69.19	12.48
2223	Physicians and Surgeons, Homeopathic	64567	5.42	0.54	94.03	-58.50	-86.42	13.39
2224	Physicians and Surgeons, Unani	10020	3.96	0.49	95.55	-69.67	-87.78	15.21
2225	Dental Specialists	21261	6.00	1.17	92.83	-54.06	-70.86	11.94
2226	Veterinarians	81584	11.25	5.66	83.09	-13.86	41.27	0.19
2229	Health Professionals (Except Nursing), n.e.c.	45036	9.98	4.18	85.84	-23.59	4.38	3.50
2230	Nursing Professionals	14343	14.03	8.40	77.56	7.43	109.86	-6.47
2230	Nursing Professionals	14343	14.03	8.40	77.56	7.43	109.86	-6.47
	B. Paramedic/Associate professionals
3220	Modern Health Associate Professionals (Except Nursing)	545579	11.62	4.11	84.27	-11.06	2.66	1.61
3221	Medical Assistants	91676	8.78	3.64	87.58	-32.78	-9.16	5.61
3222	Sanitarians	164955	14.43	4.84	80.73	10.49	20.87	-2.66
3223	Dieticians and Nutritionists	3321	10.42	2.68	86.90	-20.25	-33.06	4.79
3224	Optometrists and Opticians	12665	6.52	0.81	92.66	-50.08	-79.69	11.74
3225	Dental Assistants	2461	7.07	1.67	91.26	-45.88	-58.39	10.05
3226	Physiotherapists and Related Associate Professionals	6727	7.63	1.14	91.23	-41.63	-71.41	10.00
3227	Veterinary Assistants	27966	10.55	4.16	85.29	-19.26	3.97	2.84
3228	Pharmaceutical Assistants	221552	11.24	3.24	85.52	-13.95	-19.09	3.12
3229	Modern Health Associate Professionals (except Nursing) n.e.c.	14256	12.71	17.23	70.06	-2.71	330.33	-15.52
3230	Nursing and Midwifery Associate Professionals	583284	12.90	5.87	81.23	-1.28	46.67	-2.05
3231	Nursing Associate Professionals	491151	11.54	5.13	83.33	-11.69	28.20	0.48
3232	Midwifery Associate Professionals	92133	20.15	9.81	70.04	54.23	145.15	-15.55
3240	Traditional Medicine Practitioners and Faith Healers	11488	9.48	2.99	87.53	-27.44	-25.42	5.55
3241	Traditional Medicine Practitioners	10885	9.55	3.01	87.44	-26.94	-24.73	5.44
3242	Faith Healers	603	8.29	2.49	89.22	-36.53	-37.86	7.58
0000	TOTAL Non Agricultural WORKERS	145509200	13.06	4.00	82.93

Note: The variance has been calculated using the total non-agricultural workers, and within that the proportion of respective social group as the universe.  *Negative figure means that the proportion is lower by that much percentage as per their population proportion for the concerned social group and a positive figure reflects that it is that much higher

private health insurance entered the scene upper caste domination (being coterminous with upper and middle classes), especially of baniyas got consolidated further.

While the above data is only for a single year, the trend over time would show similar adversity for SCs and STs if not worse, assuming that the affirmative action policy has had some impact in accessing jobs and education enrolment by them in atleast public institutions. In Table 2 an abstract profile of health professionals for Maharashtra for 1991 is compiled. This shows that even in a developed state like Maharashtra which has seen many reform movements and has a politically strong dalit  movement the deficit among SCs and STs as health professionals is very high – similar to the 2001 India average. So it is clear that the impact of affirmative action for becoming a health professional is very limited and the predominance in this profession of upper castes continues to rule.

Table 2: Caste Profile of Health Professionals and paramedics in Maharashtra for all non-agricultural workforce - Maharashtra Census 1991 Economic Tables B-21 and SC & ST Special Tables

Maharashtra 1991 Census					Variance from population proportion
Occupation	Persons	%SC	%ST	% Other	SC	ST	Other
Physician & Surgeons*	92419	5.27	1.59	93.14	-49.57	-62.75	9.21
Nurses, Midwives &Paramedics	131178	14.32	3.33	82.35	37.11	-22.06	-3.44
Medical Scientists	8535	4.93	1.58	93.48	-52.77	-62.93	9.61

* Includes pharmacists and nutritionists, which in 2001 census are part of paramedics

To conclude the adverse experience of dalit and adivasi doctors, nurses and other health workers is reported regularly by the media. An excellent documentation of the personal experience of a dalit cardiac surgeon from Maharashtra reveals how difficult it is for dalits to get into the profession and when they get in, to survive. (Dr. Ashok Bhoyar – My Encounter with Dronacharya, Sugava Prakashan, Pune 2001). The dalits and adivasis suffer a double adversity of their social disadvantage as well as their class position and unless there is radical transformation in the structure of medical education and the healthcare system on one hand and the social discrimination based on caste on the other we will not witness any progressive change.

TRIBUTE/ Reminisces : Prof. Manorama Savur - 8 Nov 1927 to 14 March 2014

My first association with Manorama Savur dates back to 1978 when I joined the Bombay University Sociology Department as a MA student. We took an immediate liking for each other. She was the only professor who did not use her/his notes to teach and engaged with students in a dialogue linking the learning to the reality around us. That’s what I liked about her but many of my classmates, used to rote learning, did not like her pedagogical approach. In contrast I hated to attend the lectures of my other teachers because they taught from their notes (and as I learnt later, year in and year out they used the same notes) and would not tolerate questioning. Given my fondness for her I spent a lot of time with her discussing, questioning and getting clues to enhance my learning and understanding of the subject matter of Sociology. Our discussions were never limited to the subjects she taught and went much beyond to understand the society and political economy we lived in.

I soon got associated with Manorama Savur on one of her research projects on corporate sector involvement in rural development. This was the critical moment in my intellectual development because at that point without knowing then my arena of intellectual pursuit was taking shape. In that project I was assigned to look at the tax expenditures which were being offered under section 35cc of the Income Tax Act which provided a full tax rebate on investments made by corporates towards rural development programs[1]. Working on this project I got great insights into Savur’s thinking and intellect.

Two things drove her theorizing, one the centre-periphery relations in development (Paul Baran, Samir Amin etc..), of how the centre appropriates the surplus from its periphery – her favourite example was how Bombay had developed by exploiting its periphery, the Konkan region, especially the original Ratnagiri district, which was kept underdeveloped to facilitate the growth of Bombay, wherein a surplus labor situation was created in Konkan which would force migration into Mumbai and keep wages low in Mumbai[2]. The second theory she pursued vigorously was the “conspiracy theory”. While many intellectual peers would not agree with her on this I think because of this belief a lot of serendipitous findings emerged. For instance, in the rural development study she pushed us to believe that there was a conspiracy in the involvement of business houses with rural development programs. This led us to associate the business house’s (Mafatlal in this case) links to the government’s rural development program through which they promoted markets for its core agri-business and consequently expropriate huge surpluses. The findings revealed that the adivasis and other rural communities hardly benefited from such investments of Mafatlal but the latter’s agro business interests got a huge boost through market expansion besides the tax expenditure benefit, as well as subsidies to farmers to procure fertilizers, pesticides, irrigation pipes etc produced by Mafatlal companies making the latter’s profits zoom. My contribution to this study was the analysis of the tax expenditure element and in retrospect I now realize that this collaboration with Manorama Savur defined the pathway for my own intellectual pursuit that took me into the arena of public finance and budgets albeit within the public health framework.

Manorama Savur’s intellectual career began with the publication of her doctorate work “Freud on Man and Society” (Popular Prakashan 1965), a social psychological enquiry. But she soon changed her trajectory of work to engage with labour issues. In 1967 a 3 part series on Social security in India was published by her in the Economic and Political Weekly[3], which I discovered recently when I was engaging with the same issue focusing on social security budgets which I published both in the EPW and the medico friend circle bulletin. In 1969 she published her second book “Management and White Collar Relations” (Popular Prakashan) in collaboration with Prof SD Punekar, followed by a study of labour productivity in the tea industry in 1973[4]  which brought out sharply how female labour was exploited to expropriate maximum surplus, and later in 1988 her contribution to the ICHR series Labour Movement in India (Vol 17 1937-1939) was another great contribution to the cause of the working classes.

In the meanwhile by mid-seventies Manorama Savur had shifted to engaging with Rural Sociology, a subject she taught me, and in this pursuit consolidated her theoretical framework of centre-periphery relations and the element of conspiracy associated within such development processes. The rural development study in Gujarat and the Konkan-Bombay studies referred to above became her benchmarks to take this thinking ahead into her magnum opus research work she pursued post-retirement in 1987 from Bombay University.

Interestingly Manorama Savur’s initial academic training was in life sciences, specifically botany, before she came to Sociology. She took on a huge project under IDPAD where her training in botany helped to combine with political economy analysis to look at the disaster that was happening with the bamboo forests across the country.

The two volume “And the Bamboo Flowers in the Indian Forests: What did the Pulp and the Paper Industry Do?” (Manohar Publishers, Delhi 2003) turned out to be her magnum opus wherein her theoretical framework of centre-periphery relations as well as her political stance of a conspiracy flowers in full bloom. This study explores not only how and why the pulp and paper industry (PPI) caused the death of the bamboo forests that were an inexhaustible source of its raw material; it also investigates the impact that cultivation of alternate raw material has had upon the forest eco- system. In this context the negative role of the prestigious UNFAO which promoted the plantation of an exotic species like Eucalyptus in place of bamboo is emphatically explored. This destroyed both the natural and social history of the forests affecting adversely the sustainable lifestyles of the adivasis and other forest dwellers. The political economy of the forest-based industry has made the study many layered, into which is woven the intrigues of the FAO and other foreign agencies[5] and the nexus of the pulp and paper industry and the ply and veneer industry with the forest department. This book explores the destruction of natural forests for promotion of timber commerce across the length and breadth of the country from colonial times upto the present.

Her research contributions had huge policy implications. The rural development study exposed the misuse of tax expenditures by corporates and this was acknowledged by the then Finance Minister Pranab Mukhejee in the early eighties and strict regulation of this tax expenditure followed. Her book on Bamboo Forests has exposed the forest departments and their sell out to foreign agencies and calls for a review of forest policy. On this she took cudgels with CP Thakur Minister for Development North-East Region to stall his plans to clear fell bamboo forests in North East India[6] .

Having made these stellar contributions, surviving cancer early in the new millennium, she continued to engage with research right until she passed away at the age of 86 years. Her last piece of work (perhaps unfinished) was on document the contributions of the Bombay School of Sociology. Her death on 14^th March would have made her feel happy as she goes into history sharing her death anniversary with her intellectual mentor Karl Marx.

Manorama Savur was humble, very friendly, assertive on her perspective, loved plants, egged her students to independently find their own paths and was a very responsible citizen. She willed to donate her body to a medical college for research and use of her organs to benefit others. Her body was sent to the Armed Forces Medical College in Pune to fulfill her wish. Hers was a life lived to the full and she enjoyed every moment even when on occasions in the last decade she would be in hospital. Apart from the legacy of her creative and impactful work she leaves behind many of her students who she mentored and who work towards taking her legacy to new heights.

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[1] Manorama Savur, 1987: Involvement of Business Houses in Rural Development – A Case Study, Economic and Political Weekly, Vol. XXII No. 22, May 30, 1987

[2] Manorama Savur, 1982: Ratnagiri – Underdevelopment of an area of reserve labour force, Sociological Bulletin – Journal of the Indian Sociological Society No. 31

[3] Manorama Savur, 1967: Social Security Legislation in India, Economic and Political Weekly Vol 2 Nos 39 (Sept 30, 1967), 40 (Oct.7, 1967) and 41 (Oct 14, 1967)

[4] Manorama Savur, 1973: Labour and Productivity in the Tea Industry, EPW, March 17, 1973

[5] Manorama Savur, 2004: Rule of Foreign Agencies in the Environment, EPW, Oct 23, 2004

[6] Mnaorama Savur, 2003: Buds of Poison is a Lie, Outlook, Dec 12,  2003, http://www.outlookindia.com/article.aspx?222307

Elections Transparency and Accountability

India has over 800 million voters. The grand election circus of the largest democracy commenced in early March and this will continue until mid-May when the results are declared on May 16^th. Transparency and accountability are at the core in the present elections. Every contesting candidate’s complete information is available online on the click of a button. This information ranges from personal profile to assets and wealth owned by the candidate and his/her immediate family members, sources of income, business interests, criminal record and past electoral history and legislative performance. For some of the well-known candidates this is even published in newspapers and is discussed on television news channels. Civil Society organizations like PRS Legislature and Association for Democratic Reforms actively analyse such information and make it available in public domain. Thanks to technology there is an overload of information. So Transparency Zindabad! (Long live transparency)

Election Process Accountability

The access to such information has led common citizens and opponent candidates to pick up sensitive information and make complaints to the Election Commission (which conducts the elections) to cancel nominations of candidates. In addition huge complaints also come to the Election Commission about violation of code of conduct and these further burdens the Election Commission to investigate, monitor, issue show cause notices and take actions. So democracy is at full play. As a citizen you can record a campaign speech of any candidate on your mobile phone and send the clip having any objectionable material like hate speech to the Election Commission for review and action. While citizens participate actively in supporting the watch dog process the actions taken are often disappointing because it usually ends with a formal apology, or at best a brief sanction against campaigning in a particular region. Some violations have been exceptional and should have resulted in cancelation of candidature but the Election Commission has failed to take stringent action. Some examples below:

·         The country’s agriculture minister Sharad Pawar in one of his campaign speeches says that citizens can actually vote twice in the election because of the election being conducted in various phases. He gave an example to workers in Mumbai saying that back in your villages election is on 17^th April so go and vote there, then come back to Mumbai and vote again (if you are registered in  Mumbai also) on 24^th April. But be sure that you wipe out the election ink mark on your finger. When questioned about his statement Pawar said that he made the statement as a joke. When questioned by the Election Commission he apologised and the matter ended

·         Top BJP (the Hindu right wing party) leaders like Amit Shah have gone on record making hate speeches against Muslims and urging Hindus to vote for the BJP so that Muslims can be taught a lesson later if the BJP comes to power. A guarded apology followed and the Election Commission could not do much further

·         Candidates in their campaigns get away making casteist statements which are violative not only of the code of conduct but also the Constitution. You apologise or say you were quoted out of context and the dust settles

·         The Samajwadi (Socialist) Party leader Mulayam Singh Yadav gets away with a statement that rapists are just misguided boys and do not deserve a harsh punishment and if they come to power they will reverse the recent changes made in the rape laws that makes the punishment for rape very severe

What we observe is that transparency is very strong in terms of access to information, active citizen engagement does happen but appropriate actions don’t follow and hence accountability fails. So in this manner the election engine of India chugs along and has presently (17^th April) crossed the half way mark.

The analysis of candidate information by ADR shows that 23% candidates of the current government currently have criminal cases against them and in case of the BJP, which opinion polls indicate is the frontrunner for the new government, 34% candidates have current criminal cases registered against them. The Election Commission says that they can only disqualify candidates if they have been convicted. When political parties are confronted as to why they have put up so many candidates with criminal records they say that these are our key candidates who will help us win and if the EC has no objection then its okay. This shows the complete absence of ethics amongst political parties in selection of their candidates. The thrust of this election is that the ruling combine has been there for 10 years and it is time for Change. Is this the change voters want?

Giving Change a Chance?

In the last two years politics in India has seen huge churning. The current regime has seen its worse phase in performance with a downslide in its key flagship development programs like NRHM (health), SSA (Education), MGNREGS (employment guarantee), and food security among others due to underfunding and mismanagement. The economy’s growth is down from 9% to 5% as part of the global recession. Thanks to the CAG’s audit reports and the courts huge scams and corruption has been exposed and for the first time there have been convictions and top politicians and bureaucrats are cooling their heels in jails. So there is a general anti-incumbency mood against the present government.

Civil society organizations ran a huge anti-corruption campaign across the country demanding a strong anti-corruption law and setting up the institution of the Jan Lokpal (Peoples Ombudsman) to investigate and try cases of corruption. The campaign got politicized and in late 2013 they formed a political party and contested elections in the state of Delhi. Citizens of Delhi showed their angst against the ruling Congress party and voted them out completely. While the BJP was the largest single party they did not have the requisite numbers to form the government. So as the second largest party the anti-corruption movement now called the Aam Aadmi Party (AAP or Common Peoples Party) was invited to form the government with external support of the party they ousted. This government led by the anti-corruption crusader Arvind Kejriwal lasted for 49 days and quit as they could not get their Jan Lokpal bill passed in the state assembly. Subsequently the national elections were announced and AAP too decided to go national and is contesting over 400 seats of the 543 total.

Prior to the current elections various opinion polls have been conducted and what is apparent across the board is that people want change. Across opinion polls there is unanimity that the BJP led right wing coalition is set to cross the half way mark of 272 seats. The BJP campaign centres around its prospective Prime Ministerial candidate Narendra Modi who is a controversial figure for his support of the anti-Muslim carnage in Gujarat state of which he is the Chief Minister. Opinion polls state that there is a Modi wave across most of the country, especially in west, north and central India. Modi is viewed as a fascist with strong linkages with various right wing Hindu organizations like the Rashtriya Swayamsewak Sangh (RSS) and the Vishwa Hindu Parishad (VHP) and he idolizes Adolf Hitler. So in progressive circles as well as amongst minorities he is seen as a threat to the democratic fabric of India. So in contrast to the Modi wave that opinion polls have projected there is a silent coalition of threatened groups, especially minorities and dalits who would en masse vote against Modi. Further given that across the country regional parties have a strong presence, the likelihood of individual regional parties gaining form this duality of anti-incumbency and anti-Modi is quite high. This mathematics is something which perhaps the opinion polls may have failed to capture. So there is a high possibility that some of these regional parties would be in a strong position to call the shots post-election if there is a fractured verdict. The bottom line is that there is huge political fluidity and only May 16^th, the day of the results, will reveal the final picture. So what Change we will get for our future governance we have to wait and see. Change there will be as the voter turnout hitherto has been encouraging with over eight percentage points higher than the previous elections.

The Future of Accountability

Accountability in governance is a major concern agonizing the voter, apart from corruption. Accountability and corruption are seen as two sides of the same coin. People want improved governance. They want better social services like, health, education and welfare. They want more mileage from the taxes they have paid. They want corruption eliminated. The corporate sector too is demanding stronger governance and accountability but less government. So the mood of the electorate is clearly in favour of stronger accountability so that governance improves. This is the Change people want. Whosoever comes to power would have to deliver this or face peoples’ wrath. In the past two years people have come out on the streets against corruption and have changed the politics. If the new government fails to deliver good governance people are likely to come back on the streets. The new Government must keep this in mind and deliver good governance and be accountable to its citizens.