Academic Highlights
Updated: Jul 31
Issue 14's academic highlights discuss scholarly pieces focused on community health, caste (George, 2019) and environmental justice (Goodling, 2020).
Highlight by Hiwot
Although India prohibited discrimination along the lines of caste in 1949, lower caste communities continue to experience intersecting oppressions comprising caste identity, untouchability, socioeconomic and spatial discrimination, resulting in unfavourable health outcomes. In this article, the author examines underlying caste-based discrimination and medical power within the provider-community relationship vis-à-vis medical interactions with Dalit patients and non-Dalit patients, and how they lead to differential treatment and quality of care by providers. Whilst the official term for lower caste communities is scheduled castes, the term Dalit is used in this review as per usage by the author.
The analysis was guided by a prior ethnographic study, which involved non-participant observation and in-depth interviews with 50 Dalit patients, women and men of mixed age and occupation, at selected local public health services in the, predominantly, Dalit, village Meenkera. George considers closely whether there are differential treatments unfavourable to Dalit patients, how they are expressed, perceived and normalised in the context of dual forces, caste and medical power via-a-vis caste supremacy held by the service providers.
Findings revealed caste embeddedness in the public health facilities observed. Namely, higher ranked positions, for example, doctors, were dominated by non-Dalit castes. There were significant differences in how medical providers communicated, examined, and treated patients from lower caste communities compared with those from higher caste communities. Integral components of care delivery such as ‘touch, …asking questions, listening…, showing concern…’ were compromised, and, instead, transpired as touch avoidance, apathy, negligence, stopping Dalit patients from talking, speaking offensively, using differential styles of address, and prioritising higher caste groups. Touch avoidance by providers, pertaining to purity and pollution, was reported by Dalit patients as a common experience, for example, “The nurse doesn’t…give the injection smoothly. She just injects it through our clothes…”. Dalit patients also reported that “…doctors did not hesitate to touch ‘other people’ whom the respondents described by using words like ‘rich’, ‘clean’, ‘educated’…, ‘powerful’, and ‘influential’”.
The article found that, first sight identification of Dalit patients was routinely practised by providers, based on ‘…name…, dress, skin colour, appearance, education, job, manners, way of talking…and sometimes even body odour…’. Such provider practice would appear to serve in maintaining caste-related stereotypes and used as markers of caste identification by medical providers, in their interactions with patients. The author advises that, ‘Caste, in such situations, becomes an explicit corporeal reality for Dalits.’ Though discrimination is a unifying factor in Dalit communities, the article recognises that there are various experiential dimensions of caste, which are situation dependent.The Dalit patient narratives articulated how the differential shared conditions of Dalit and non-Dalit patients, respectively, shape differential access to power, for these communities, in medical interactions, in turn impacting their treatment, quality of care and consequent help-seeking.
The author establishes that it is the camouflage effect of caste and allopathic medical practice, dual power structures enmeshed within the provider-patient interaction, which enable the normalisation and perpetuation of caste-based discrimination. This appears evident in the paternalistic composition of the medical interaction where the provider represents medical authority and caste superiority, and the patient is often from socially disadvantaged communities, rendering it difficult for patients to distinguish between expressions of caste discrimination and medicine.
Collective resilience, in the form of strong Dalit consciousness, appeared to prevent most patients from attributing compromised care received to their caste, but rather to the general faults of public health services. The author, however, maintains that the reasons attributed by Dalit patients to their differential treatment, such as being, ‘poor, ignorant, dirty, smelly, uneducated and less powerful’ cannot be detached from caste. Caste-based discrimination within the provider-community interaction appears to present a microcosm of the wider ongoing hierarchical caste-based separation of communities in Indian society and serves to further demarcate and extend man-made polarised spheres of superiority and inferiority, visibility and invisibility within communities.
Highlight by Sonora
In this article, Goodling (2020) presents a Critical Environmental Justice analysis of homelessness in the US, examining its intersections with racism and wide ranging health hazards. The paper presents the findings of a qualitative survey of 47 houseless community representatives across 19 states in the US. It is one of the most thorough efforts to map the geography of houseless communities and the environmental hazards impacting their health and wellbeing in the country.
As discussed in this paper, a key pathway through which discrimination impacts individuals’ health is by shaping communities and corralling marginalised people into health-harming places (Selvarajah et al. 2022). This is foundational knowledge born from the Environmental Justice movement that originated in the US in the 1980s in response to the siting of toxic industries and waste in majority Black and minoritised communities. In the background section of this article, Goodling (2020) synthesises the development of Environmental Justice into Critical Environmental Justice. Central components of this development are an increased focus on intersectional forms of oppression and an expanded approach to justice that includes procedural justice alongside the attention to distributive and juridical justice.
Both intersectionality and procedural justice are central to Goodling’s analysis. Goodling describes the cycles of criminalisation, exposure and eviction that unhoused people face in the US. Unhoused people face increasing criminalisation of homelessness, resulting in frequent fines, ‘move along’ orders and evictions. This forces them to live in areas of increasing environmental risk where they are exposed to hazards that harm their health. Where unhoused communities report the environmental hazards in their areas of residence, the government agencies most frequently respond by evicting them from these new areas of residence without providing suitable alternatives. Goodling demonstrates the procedural injustices rife within this cycle, as police and government officials unfairly and sometimes illegally treat unhoused people. She also details how procedural injustices uniquely impact Black and Native unhoused people, for whom the intersectional oppression of racism and houselessness can have deadly consequences.
For readers interested in environmental racism and intersectionality, I highly recommend this paper. Goodling provides a wealth of qualitative data to highlight the intersectional exposure to environmental hazards that she describes and clearly articulates the role of policing in environmental injustice faced by minoritised, unhoused people. This article also provides a clear overview of theoretical developments on original environmental justice literature, which is fundamental in contemporary understandings of racism and health at the community level.