World Science Day: Why it is urgent to address caste-based discrimination in Indian medical institutions

In September 2017, S Anitha, a Dalit girl from Ariyalur district of Tamil Nadu (TN), died by suicide after she was unable to secure admission in a medical college. The Supreme Court (SC) in the same year had ruled that admissions to medical colleges in TN will be based on marks obtained in the National Eligibility cum Entrance Test (NEET), conducted by the National Testing Agency for admission to undergraduate medical courses in India. Anitha, who had scored 1,176 marks out of 2,000 in her 12th board exam and 12.33 percentage in NEET while the minimum cut-off for reserved category students was 40 percent, moved the Supreme Court challenging NEET and was known to have spearheaded the movement against the all India medical entrance exam.

Since 2017, such reports of students' suicides caused by NEET, especially in TN, have repeatedly led to protests calling for a NEET ban. According to a study published in the Indian Journal of Psychological Medicine, 32 cases of suicides of NEET aspirants were reported between 2018 and 2020. This year, five NEET aspirants died by suicide until October 31. The death of Anitha and many other SC, ST students have triggered discussions about the system of medical education in India being unfair towards students from marginalised communities such as the Scheduled Castes, Scheduled Tribes and the Other Backward Classes, in terms of lack of access to resources including hefty fees for coaching classes for NEET and to study in a medical college.

According to data from the All India Survey of Higher Education (AISHE), of the total 2,87,776 students enrolled for the Bachelor of Medicine and Surgery (MBBS) course, only 26,658 students (9.2 percent) belonged to the Scheduled Caste communities and 12,552 students (4.3 percent) belonged to the Scheduled Tribe communities. Similarly, for Bachelor of Dental Surgery, SCs and STs accounted for only 8.8 percent and 2.4 percent of the total enrolment.

Among the 17 categories of courses mentioned under medical science education in AISHE, MBBS and Dentistry are two of the major courses, where representation of the SC, ST communities presents a dismal picture. While the All India Quota--provided for students who wish to study in any medical college outside their state - for SC students is 15 percent and for ST students 7.5 percent, data shows the set quota is not fulfilled.

On the occasion of World Science Day for Peace and Development, public health expert Dr Sylvia Karpagam sheds light on the barriers which discourage SC, ST students from taking up medical courses and highlights the many ways in which Indian medical institutions are caste-ridden.

What does the gap in the above mentioned numbers say?

One needs to understand that the caste system has created a situation of unfair advantage to some communities and left many other communities behind.

The MBBS course is for 4.5 years, followed by an internship of one year. During this period expenses may be quite a lot for the student in spite of scholarship or reservation. Also many medical colleges may not pay a proper stipend and a number of SC, ST students may not be able to sustain financially during this period. There may not be additional support classes such as English language classes held for students who have studied in regional languages. The added pressure of earning an income to support the family further discourages them from taking up MBBS and other niche medical courses.

For children from SC, ST communities to reach medical college and to thrive, all barriers to their development should be addressed. Just putting a percentage on paper will not allow age-old caste oppressive structures to disappear. It would also be important to see how many students drop out after joining and why. This might happen in most higher education courses, so studying that in depth is also important.

What are the main factors that discourage students from the SC and ST communities from taking up medical courses in India?

Medical education is very elitist in India with mostly English speaking, urban students; this itself can be daunting for a lot of students from vulnerable backgrounds. Additionally, scholarships are erratic and not disbursed on time. If a student joins medical college, the rigid fee system leads to extreme mental stress, thus increasing the possibility of dropping out.

Second, they may be aware of the harassment that others from their community may have faced, which adds to the lowered self-esteem and the fear of entering these spaces. It is very unlikely that oppressor caste groups, who feel entitled to these educational spaces, would be welcoming towards students from reservation. Even in public institutions that by nature must belong to all citizens and are run on tax payers' money, the sense of entitlement of oppressor caste groups to these spaces is very visible in their everyday interactions.

Higher education is a luxury except for those who have pensions, family wealth and other economic support mechanisms. In spite of reservations, students may have expenses for which they may not have the resources. The government has to improve livelihood opportunities, ensure decent housing, public transport, public libraries, and nutritious mid-day meals to the children from marginalised communities. It must also ensure that scholarships meant for such students are being released on time. Bringing in anti-discrimination policies and providing legal recourse to justice are other important measures.

In what ways does caste exist in medical institutional spaces (government and private) and how does it impact the lives of the on-campus students belonging to the marginalised communities?

Caste exists in both overt and covert forms. Overt casteism such as usage of abusive language can be humiliating and extremely damaging to self-esteem. When this happens for a long time and without any recourse to grievance redressal, it can seriously affect the students' mental health. Often they are held responsible for their own harassment.

Another aspect that needs to be explored is how persons from vulnerable and marginalized communities perceive and deal with exclusion from social spaces. Who gets invited to parties, who gets to speak at public forums, who the professor wants as his or her ‘assistant', who gets access to conferences etc. is important to document. In such situations, how do students and teachers from vulnerable communities respond, either to avoid discrimination or to be included? Do they change their behaviour in overt or covert ways? How does this affect their professional performance? Does it mean they spend less time studying and more time feeling bad? Or do they offer to do extra work to get the faculty's appreciation? Do they ask more or less questions? There is a need for qualitative questioning that draws out these nuances, which will help understand the entrenched ways of exclusion and discrimination.

Discrimination based on food habits such as with those eating meat is also normalised. The pressure from teachers may increase, bullying from peers may aggravate, and the community itself may indulge in some sort of social boycott. All of these are powerful ways in which caste hierarchy is reinforced.

At a time when we have been witnessing the institutional deaths of SC, ST medical students and doctors, according to you what could regulatory bodies such as the Medical Council of India or Indian Medical Association have done for providing a safe space for learning and equal opportunities of growth to the SC, ST and OBC students in medical institutions?

The Indian Medical Association cannot be ignorant towards the discrimination that exists within medical and healthcare institutions. There needs to be a system to actively identify them and address them. The present attitude could possibly be the result of the lack of diversity and representation within the leadership of the IMA. Most of the time, protecting the reputation of the medical fraternity becomes the overarching concern and anything that damages this image is quickly suppressed. This suppression doesn't mean the issue has disappeared. Offering students, staff and faculty the space and words to articulate covert discrimination is an important aspect of affirmative action and diversity. Having annual staff parties where all staff children are invited and given cakes and balloons isn't affirmative action. It is whether the rights of the person who is most vulnerable are respected and more importantly whether they have access to justice if these rights are violated.

Importantly, healthcare professionals need to ask themselves where does discrimination fit into the larger principles of medical ethics. Doctors say ‘we do not discriminate' and maybe they don't in overt ways, but it is important to introspect on personal prejudices as well. That is the only way forward to create a more humane and compassionate healthcare system.

What are your observations on the NEET exams, its impact on students from marginalised communities and how it can be tackled?

The NEET exams are based on the CBSE syllabus which is not followed by many students from State boards in the country. Those who follow the state syllabus are at a distinct disadvantage and over time only students from urban areas are becoming more and more dominant in medical education and all principles of social justice are thrown to the wind.

Admissions based on marks obtained in higher secondary education exams rather than national tests saves crucial time for SC, ST students who cannot afford to spend 2-3 years in coaching classes preparing for entrance exams, which have become the lucrative norm in many states. NEET system also takes away the autonomy of the state governments and brings in a centralised model when more states are struggling to provide even basic healthcare facilities and have unacceptably poor health indicators. Tamil Nadu has a strong reservation or affirmative action policy than most other states of the country. That the Central government is heading to destroy this model shows the vindictiveness more than any attempt to follow evidence based policy making.

When we talk about public health, could you explain why representation in medical sciences is important and what is the role of reservation in it?

Discrimination has to be looked at from two perspectives - one is within the healthcare system and the other is by the healthcare system.

Our healthcare system is highly corporatised, urban and doctor-centric and hardly has any regulatory checks and balances. The doctors are often from dominant castes and everyone else is secondary. At the other end of this spectrum are the workers, often Dalit, who face every day discrimination and violation of their dignity and basic rights. These are the housekeeping staff, the people working in mortuaries, the ambulance drivers, and the sanitation workers who handle hospital waste, excreta and are cleaning bodies etc.

In the absence of systems in place to identify and address discrimination in cases where it does occur, there is little scope for someone affected by discrimination to actually place their arguments. This is where representation comes into picture.

Though reservation is constitutionally mandated, the hatred for it and obfuscation of it by people from dominant caste groups is so rampant that it has become normalised. Looking at the tweets that have been shared so confidently and brazenly in public by senior and junior doctors, only gives an idea of how virulent the problem would be.

The dominant caste person is eternally projected as the suffering victim who would have got a medical seat if only reservation wasn't there. The other discussion is that SC, ST students whose parents are well off, should, on moral grounds, give up affirmative action or reservation. They fail to realise that SC, ST students, irrespective of economic backgrounds, still face undue disadvantage when competing with a dominant caste student. Personal affiliations, references, corruption, caste networks are largely ignored in this narrative.

It is also a problem that neither their colleagues nor seniors nor management (who are often from the same dominant caste groups) call out casteist behaviour and in fact participate, enable overtly and covertly. There is an entire culture of impunity around caste-based discrimination especially in the sense of victimhood that is created around reservation.

(To overcome suicidal thoughts, reach out to these organisations: Aasra- 9820466726, Roshni- +914066202000, Sneha India Foundation- 044 2464 0050)

Also Read: Why caste is in focus when discussing violence against Dalit women