When a 40-year-old woman from India’s lowest caste group visited her district-level hospital a year ago because she was running a high fever, the doctor refused to even touch her throughout the medical check-up.

However, Bharati Sonkar was a social activist from Bhopal in the central Indian state of Madhya Pradesh and she wasn’t going to let this pass. She discussed the incident with other local women from her caste group – the Dalits – who are subjected to caste-based discrimination.

After discussing the incident at the hospital, Bharati realized that others had been treated in the same manner by the same doctor. When they joined forces and complained to the District Medical Officer, the doctor was forced to change her ways.

No formal complaint was lodged against her, although it is a punishable offense to practice untouchability, which is the exercise of ostracizing and segregation of lower caste groups in Hindu social structure.

Healthcare related discrimination against Dalit women is a common occurrence in India. The latest National Family Health Survey (NFHS) data states that 70.4% of the Dalit women surveyed said they had problems accessing health care. Bharati added: “I have faced ill-treatment at AIIMS and Jawaharlal Cancer Hospital in Bhopal as well. ”

Released on January 2018, the NFHS report states that the average age when Dalit women die is 39.5, as against 54.1 for an upper caste woman.

Gayatri Sonkar, who works with the All India Dalit Mahila Adhikar Manch, said: “Dalit women are discriminated at all levels of health care. I have seen cases where the midwives in charge of delivery have been harsher with Dalit women and been unsympathetic to their pain.”

Access to healthcare

The caste-discrimination also affects access to basic resources in health care. “It is more difficult for us to arrange for an ambulance,” says Gayatri. In November 2017, a pregnant Dalit woman in Ranni, Kerala, delivered a baby alone at home. Her husband, after calling two hospitals repeatedly and asking them to send an ambulance, had to rush out to make alternative arrangements for a vehicle. The mother and the baby were eventually taken to the hospital in a police vehicle.

The latest NFHS report states that one in four Dalit women aged from 15 to 49 is undernourished, according to their Body Mass Index. Amongst upper caste women, the ratio is one undernourished woman for every six. The NHFS report is only the latest in a slew of studies that have reached the conclusion that Dalit women lag behind on almost all health indicators, have poorer access to healthcare and dying younger.

A structure of discrimination has led to this situation faced by the women from this historically oppressed caste group. A report released in 2015 by the Lancet medical journal titled “Health and the Indian Caste System” listed three ways in which caste impacts health – genetics, early environment and opportunities as a result of social mobility.

The lack of social mobility and poor economic conditions also hinder healthcare access.

“Sometimes the closest healthcare facility is far away and the only way to get there is an ambulance. This costs more than most Dalit families can afford. Money is one of the main reasons why many Dalit women end up going to quacks who practice black magic,” said Gayatri.

The NFHS data found that 70.4% of Dalit women reported difficulty in accessing healthcare when they needed it.

Burden of being a Dalit and a woman

In 2017, an 18-year-old Dalit girl was raped in Madhya Pradesh. During her medical examination, the doctor told her: “If they had forced themselves on you, there should have been marks on your body, but you don’t have any. You must have done this of your own free will.”

Bharati believes that Dalit women are more vulnerable to such treatment by doctors and nurses. She said: “Two years back I was admitted in AIIMS Bhopal for a serious operation after which I had several stitches on my stomach. They forgot to remove a stitch and I had to come back when I realized they had botched up.”

Bharati also says single Dalit women are more vulnerable as authorities often do not give them enough information about their condition or the treatment they are being made to undergo.

This gave way to a private IVF clinic in Vizag facing allegations of tricking a Dalit woman into surrogacy. The woman claimed she had been led to believe that she would be donating an egg. However, the clinic performed an embryo transfer without her consent.

A United Nations report released in February 2018 titled Turning Promises into Action: gender equality in the 2030 agenda, takes note of caste, gender and health. It highlights that the intersection of gender with other forms of discrimination, such as caste, makes girls and women the most vulnerable.

In a paper titled ‘Dalit Women in India: At the Crossroads of Gender, Class, and Caste,’ authors Nidhi Sadana Sabharwal and Wandana Sonalkar wrote “additional discrimination faced by Dalit women on account of their gender and caste is clearly reflected in the differential achievements in human development indicators for this group. In all the indicators of human development, for example, literacy and longevity, Dalit women score worse than Dalit men and non-Dalit women.” For instance, if one looks at the category of education, the 2011 census data says 47.2 million Dalit women were less literate (56.4%) as compared to 66.4 million Dalit men (75.1%).