medico 357-360 friend circle bulletin July 2013 - February 2014 Concept Note for the 40th Annual Meet Social Discrimination in Health (with reference to Caste, Class, Gender and Religious Minorities) - E. Premdas Pinto and Manisha Gupte1 Introduction Theme will focus on the issues of social exclusion The 40th Annual Meet of the Medico Friend Circle and discrimination which continue to haunt the (MFC) being organised in Delhi from February 13- lives of subordinated groups through societal 15, 2014, takes place at a very critical juncture in the structures and policies which favour the status-quo public health history of India from the point of view of such structures that have serious consequences of the socially disadvantaged communities. Medico to health of the disadvantaged and the marginalised. Friend Circle was initiated four decades ago (in Experiences of communities that have been, and 1974) by visionaries of an alternative society, in the still are, discriminated and stigmatized on the basis backdrop of the social ferment and social movements of caste, class, gender orientation and religion. of the 1970’s within the JP Movement (Movement Such experiences are further aggravated through a led by Jay Prakash Narayan). This history has had combination of neo-liberal policies, by the practices an overwhelming influence on the thinking of MFC of privatization, by the incidence of communal and members in terms of envisioning a society based ethnic conflicts, and by the continued violence on on equality, democracy and social justice, and with the basis of gender or sexual orientation. the understanding of health in its broadest sense Social Inequalities and Unequal Health – encompassing its social determinants, and as an Outcomes indicator of human dignity, and individual as well as community well being. MFC has been a witness There has been a growing literature endorsing the to the history of people’s health in India through the hitherto known common sense understanding that last four decades (1974-2014) with uninterrupted socio-economic inequalities lead to unequal and Annual Meets, a bi-monthly bulletin, as well as adverse health outcomes. The Black Report in in terms of taking principled positions offering England, research by Michael Marmott conducted critical responses to challenging issues to the health in fairly well-off societies such as United Kingdom, of the marginalised communities in India. In spite etc., have substantiated this argument (Marmott and of MFC being a completely voluntary group, with Wilkinson 1999). The Report of the Commission expenses being shared by members who work on Social Determinants of Health (CSDH) of country-wide in health-related organisations, it has World Health Organisation (WHO – CSDH been involved in campaigns, research, fact-finding 2008) has articulated well that health is beyond and dissemination of crucial information to the clinical/medical/health care and that health care public. At a time when the marketised, privatized, per se is influenced by various socio-political fragmented and reductionist understanding of and cultural factors. These various determining health is promoted, the theme of 40th Annual Meet factors influencing the health status of individuals is social discrimination in health with reference to and groups are summarized under the present day caste, class, gender and religious minorities. The coinage of “social determinants of health”. 1 The authors acknowledge inputs from Prabir Chatterji and Ravi Duggal. Email of authors: <[email protected]> and <[email protected].> 2 mfc bulletin/July 2013 - February 2014 The impact of social discrimination on health is ecosystems, and in particular as linked to the studied by various scholars especially using the eco- alienation of indigenous populations from their social theoretical framework. Most of these studies lands. are done keeping race as the axis of discrimination, Difference, Inequality, Inequity, Exclusion and especially in United States of America (USA) Discrimination and Europe. According to this framework, racial discrimination, a form of social discrimination and Differences, inequalities and some form of hierarchies societal injustice, becomes “embodied inequality” seem to be part of the societal functioning. We also and manifests itself as health inequities. The eco- uphold the value of being different and diversity. social theory is very pertinent to understand and Hence, sameness is not being advocated by us as a conceptualise social discrimination in relation to virtue for health, wellbeing and dignity. The key health. This theory of disease distribution concerns challenge is, however, to see when and how these who and what drive social inequalities in health. differences, inequalities and hierarchies become [A central focus of this framework is on how we institutionalized by a) restricting access to resources literally and biologically embody exposures arising which are essential to a dignified living and b) giving from our societal and ecological context. This is rise to socio-politico-economic structures which reflected in the distribution of health and illness exclude and discriminate communities without among populations. The eco-social theoretical power and resources. framework, inter alia, has relevance to the theme of social discrimination that MFC is discussing about. These structures give rise to social discrimination The axes of discrimination in such a discussion which is legitimized in the name of caste, race, would be caste, class, gender and religion. religion, ethnicity, gender, etc., and, in turn becomes the media to perpetuate inequity. Discrimination - The core constructs and core propositions of this based on caste, class, religion and gender, identity theory are well enunciated (Krieger 2012). Some of in the community - is the outcome of a system that the core propositions of this theory include: is infected with this structural malaise and play out in all spheres of life. The lower, one is in the power • People literally and biologically embody their hierarchy, the more adverse the impact of health, lived experience, in societal and ecologic context, dignity and wellbeing. thereby creating population level patterns of health and disease; Political Economy of Social Discrimination in Health • epidemiological profiles of societies are shaped by the ways of living afforded by their current Discrimination is generally understood as “unfair and changing societal arrangements of power, treatment of a person or group on the basis of property, and the production and reproduction prejudice” (Webster’s Dictionary). Prejudice is of both social and biological life; embedded in social structures and institutions. Though social stratification is a given thing in the • in societies exhibiting social divisions based social processes, due to the unequal appropriation on property and power, the greater burden of of resources and power, many individuals and disease is on those with lesser power and fewer communities are rendered vulnerable due to the resources, lack of ownership over and access to resources. The Among the core constructs of this theory, two are of injustice experienced by the poor this way ranges special significance to the theme of discrimination from exclusion from enjoying equal opportunities in health: and resources to being targeted through expressed violence through stated or unstated societal sanctions. (1) embodiment (we literally embody biologically, The data on anaemia, children dying of malnutrition in societal and ecological context, the material and hunger, maternal mortality, infant and neo- and social world in which we live); natal mortality, low literacy and inadequately paid (2) diverse pathways of embodiment include a range labour, migration in search of livelihood, etc., of phenomena: social and economic deprivation, point to communities who experience systemic exogenous hazards, hazardous conditions, and continuous discrimination through the inbuilt social trauma, discrimination and other forms of institutions of caste, class, gender constructs and mental, physical, and sexual trauma, inadequate religion. The adverse health outcomes, in a sense or degrading health care, and degradation of are not only an indicator of the public health delivery mfc bulletin/July 2013 - February 2014 3 system, but more so of the foundations of prejudice Link and Phelan (1995) described socioeconomic and discrimination within which the public health status, social networks, and stigmatization as system is located. Dalit women who are brutalized, “fundamental causes” of disease. Link and Phelan Muslim communities who are the constant targets maintained that these factors shape access to of right wing religious hegemonies, manual significant salutary resources that ultimately scavengers who are unpaid and have no option but influence health, such as money, knowledge, to do manual scavenging, sexual minorities who are power, prestige, and social support. They suggested criminalized due to their sexual orientation, tribal that fundamental causes can affect health through women and poor who become easy prey for clinical multiple mechanisms and are not disease-specific. and medical experiments - they all tell stories of Further, as root causes, these factors continue to horror of indignity experienced due to the unjust influence health regardless of the effectiveness of social structures where privileges are reserved for individual treatment or therapy. Even as knowledge