This Fissured Health: A Report on the Healthcare Delivery System from ‘Outcaste’ India

Contributors: Adithya Beera, Dishani Roy, Sagnik Bhattacharya, Sreemoyee Paul, Sucharita Sarkar

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Representational image of ASHA workers engaged in COVID-19 duty(Photo | S Senbgapandiyan, RVK Rao, EPS)

Prelude: The Outcast Physician: An Embedded History

As Sheldon Pollock put it, South Asia has long been the home of some of the world’s best stories and it is only appropriate that any investigation into tendencies in Indian Civilization begin with one of the myriad tales she has held in her belly. For in India, as in many other non-Western cultures, it is not in externalized forms of historical writing that the past of its people lay exposed, but concealed in embedded forms of historical consciousness that it finds expression in the form of tales, legends, and myths. Students of Indian history with an interest in extracting civilizational tendencies, are grateful to the interventions of Romila Thapar in crafting out a methodology for studying the said mythic corpus in order to unravel un-written and un-charted histories. And so, we begin with one of the most famous stories of the Puranic-lore: the tale of Daksha’s yajna.

In a time beyond what the record of history allows up to locate with any precision, the priest-king Daksha (one of the sons of the Hindu Creator-God Brahma) had arranged for the performance of a yajna [Hindu fire sacrifice] to which all the Gods were invited. All the Gods except Shiva and his wife, Daksha’s youngest daughter Sati. The king was so repelled by Shiva for what he regarded as Shiva’s ‘intoxication’, ‘impurity’, and ‘indiscriminate roaming among all peoples’ that he considered it sacrilegious to allow him near the consecrated grounds of the fire-alter. While the trident-bearing Shiva made peace with not being invited, his wife was furious and demanded that at least she be allowed to go nevertheless. When Shiva protested, the Goddess assumed ten fierce blood-curdling forms (known in the Hindu pantheon as the Dasha-Mahavidya or the ‘Ten Great Wisdoms’) to scare and convince her consort. When finally Shiva, the most-ancient-of-the-Gods, relented at the sight of Sati assuming the form of ‘Chhinnamasta’, Sati went to her father’s yajna -- only to be humiliated for her choice of husband and for arriving uninvited. Rejected and shamed, Sati immolated herself in a mystic fire - and the Goddess disappeared from the face of the world.

Behind this sad story lies embedded (which is the term Romila Thapar uses to describe the quintessentially Indian historiographic tradition) a Deep History of South Asian civilization that can at best be called shameful.

From what little historical sources tell us, in the second and early first millennium BCE, (known as the Vedic Age) the limited degree of social stratification did not allow for much class or caste division. Priests, kings, physicians, workers, herders and peasants lived together in symbiotic relationships which although not perfect were far-removed from the violent relationship they would develop in the following centuries. With the settlement of the ‘Indo-Aryans’ in the Gangetic valley and the societal complexity that it gave birth to, the job of the gatekeeper of life-and-death in the increasingly caste-segregated and violent society of the period came to be concentrated in the hands of the priest-caste (i.e., the Brahmins) meaning a total outcasting of the ‘physician-healer,’ marginalization of medical knowledge, fall of the Vedic Ashwin(s)--deities of medicine, and a rejection of the nurturing ‘Devi’ in favour of the Brahmanical (mostly) male deities. Not only the shudra(s) and the atishudra(s) but later-Vedic and post-Vedic scripture declared even the physician as essentially ‘unclean’ and the Shatapatha Brahmana--a commentarial text on the Yajur Veda (ca. 300 BCE) barred them from the hallowed grounds of the yajna. And herein, lies the embedded reason for the exclusion of the Vaidyanath (Lord of the Physicians) Shiva from the grand celestial yajna of Daksha. And for two thousand years, Daksha’s daughter--the nurturing Goddess, wandered along hills, forests and borderlands as local deities of healing and nutrition--as Olachandi, Manasa, Shitala, Van Devi, Janguli, and many others.


While Indians like to (rightfully) bask in the glory of Charaka and Sushruta, who did indeed do revolutionizing work in the field of medicine and surgery, the consistent ‘outcasting’ of physicians since the later Vedic Age is a dark underbelly of Indic civilization that is often left out of public memory.

Prodding deeper and beyond the embedded meaning of this legend (or ‘itihasa’ in the Indic sense of the term), it is not difficult to find that the disdain for not only the sick but the physician too derives from a rather careful (nevertheless wrong) conception of the communicability of diseases that fundamentally underlie the marginalization of the sick and the physician. This can be clearly derived from the verse in the Manusmriti (4.220)

puyam chikitsakasya annam

bhishaje puuya-shonitam

[Unclean is the food of the physician

Unclean as the pus and blood.]

Such an aversion, is an aversion that according to some, is coded genetically, while others believe is an aversion that is learnt. Whatever it be, what concerns this present project is that such an aversion to “potential” sources of infection functioning within the logic of bio-politics, comes very close to a set of ‘doctrines’, or the driving principle, on which stands the phenomenon of caste-segregation. Understood in terms of Mary Douglas’ (1966) notion of purity and danger, the identification of ‘caste’ and ‘tribe’ groups as intrinsically polluted achieves new meaning when they are interpreted in the parlance of the world after the epidemiological transition.

Abdel Omran, a Cairene epidemiologist, in 1971 formulated the theory of Epidemiological Transition which up until that point was a poorly defined cluster of ideas as, which explains change in demographics taking into account parameters like fertility, mortality and leading causes of death. Omran distinguished the “The Age of Pestilence and Famine”, where mortality rate is at its worst and unstable, and the leading cause of death being infectious diseases and communal malnutrition with “The Age of Degenerative and Man-Made Diseases” where mortality rate is relatively much lower and positively correlated to lifestyle diseases like cardiovascular diseases, violence, accidents, eating habits, substance abuse, etc. Chronic diseases rising out of human behaviour patterns has replaced infections as the leading cause of mortality. It was in 1998 that Ronald Barret et al. added a post third stage phase to Omran’s theory of Epidemiological Transition which states disease is largely modulated for those that have access to quality healthcare and education and in the long run, inequalities persist. Socioeconomic, gender, ethnic and caste based inequalities continue to haunt the differences in fertility and mortality.

In the last five decades or so, medicine has established itself as an efficacious section of science when it comes to the battle against fatal diseases. But it has also brought upon a rude exposure of the ever expanding social aperture in the availability of medicare for the privileged few and the lack thereof for the underprivileged many. This intentional misfortune can be attributed to the four horses of epidemiological apocalypse: overpopulation, extreme poverty, consumerism and ignorance.

Ignorance can be broadly categorised into two types, namely indigenous and foreign. While the concept of purification “atonement” attached to human suffering as believed by certain sects of theists leads to not reporting to a medical facility on time, ultimately becoming a self fulfilling prophecy, is an excellent example of indigenous ignorance. But for a plethora of reasons, the impurity construct

The concept of Epidemiological Transition employs patterns of disease and health with their demographics, social determinants and results.

Mary Douglas (1966:42) argued that defilement is never an isolated event but rather impurity or dirt is a by-product of a systematic order of ideas. Positive and negative precepts are held to be efficacious and if observed they bring prosperity, infringing them brings ‘danger’ (Douglas 1966:52). Douglas (1966) demonstrated from Leviticus (third book of the Torah and of the Old Testament) that the stress is laid on physical perfection of things presented in the temple and of persons approaching it. The animals offered in sacrifice for instance, have to be without blemish, women must be purified after childbirth, etc. All bodily discharges and contact with death are held to be defiling and disqualifying from approach to the temple. From this, Douglas (1966: 53) concluded that the idea of ritual purity is to do with an external, physical expression in the wholeness and cleanness of the body and this is extended to signify completeness in a social context.

Upon close introspection, caste dynamics demonstrate similar attitudes and practices where dirt is taken to be dangerous to ritual purity. Harper (1964) and Srinivas (1952) have found a three-way classification of ritual purity: maDi (ritual purity), mailige (normal ritual status), and muT- TuceTTu (ritually impure). Harper (1964) supported Srinivas's assertion that purity and pollution are connected with punya (merit), paapa (sin), and auspiciousness. Dirt (alukku) and germs (kirumi) are distinct but related to acuttam (unclean) (Bean 1981). According to Bean (1981), alukku is more external and acuttam is more internal and affects the whole being. Ryan (1980 cited in Bean 1981) finds an association between acuttam (unclean) and kurram (fault). Srinivas (1952) linked purity with "good sacred- ness" and "auspiciousness." Moreover, Bean (1981) finds that in Avaruru Kannada, "purity" is linked to goodness and opposed to badness, and to civilized in opposition to uncivilized. McGilvray (n.a. cited in Bean 1981) similarly states that tuTakku (ritual pollution) is sometimes held synonymous with kurram (fault, blemish) or toosham (malevolent influence; similar to the relation between "pollution" and daaridara (misfortune) in Avaruru.

Bean (1981) generalized the fact that "proper order," "proper execution," "well orderedness" are intrinsic to the meanings of terms for "purity" and "cleanliness," while "messiness" and "not proper order" are intrinsic to the senses of terms for "dirt" "defilement" in the Indian context. This is in line with Mary Douglas's (1966) argument about the nature of purity. Moreover, Bean (1981) found that things and people considered to be "polluted" (here, aNTu, mailige, suutaka) are avoided and kept apart (infection through contagion, menstruating women, families mourning, Untouchables) because not only their "defilement," but also their disarray, is considered dangerous to others.

Ample of literature on epidemiology of caste (George 2019; Pol 2020; Verma and Acharya 2018; Barik, Debasis, and Thorat 2015) cite instances where people from the lower castes were discriminated against by health care workers as they were taken to be dangerous carriers of germs. Dasgupta and Thorat (2009) have stressed that followed by tribes, Dalits in India have the lowest immunization rate. The same was also reflected by National Family Health Survey-3 (NFHS-3) data. Acharya (2010) notes that it is mainly because touching is involved in the vaccination process. He further notes attitudes of humiliation and indignation meted out towards the people of the Dalit community when they try to access health care facilities. For instance, during diagnosis they are almost given no time and doctors avoid touching them during the process (Acharya 2010). Even during laboratory tests, touching their bodies directly during x-ray or other tests are avoided (Acharya 2010). Medicines are dispensed by health care workers through a piece of paper to avoid touching their hands or someone else is asked to give them the medicines or the medicines were kept on the window sill or floor (Acharya 2010).

There is a general belief amongst people, that the people from Muslim community and Dalit community are the chief spreaders of the Covid virus since they mostly live in unhygienic conditions and at the same time, there is a common consensus which holds them most resistant to the disease due to their strong immunity as a result of continuous exposure to dirt and germs. Even scholarship on Colonial epidemics suggests similar opinions of the caste Hindus against the Bhangis (perceived as untouchables). For instance, Sheldon Watts (1999: 183) notes a report on Cholera epidemic of colonial times by Enthoven: “Enthoven's observations of popular customs raise a fourth point: the transference of the disease "to the Bhangis," the lowest caste, the untouchables. It would seem that in Bombay such people were regarded as having a touch of magic about them that enabled them to deal with catastrophic diseases before which ordinary indigenous professional health workers were helpless.”

In order to understand the lags in the process of the epidemiological transition in India, it therefore becomes extremely important to understand the social determinants in epidemiology and the exact mechanism through which the Indian republic (both Central and State) attempts to achieve the transition in real terms.

In epidemiological terms, scientists identify a number of factors that serve as major determinants in analyzing the healthcare system of a given community, as well as in predicting and charting the course that infections may take through a certain given population. These epidemiological determinants vary from age, to sex, from the demographic divident to the sex-ration of a given population. But what is particularly relevant for the purpose of this study, is what are known as the Social Determinants of epidemiology. These social determinants include class and race just as they include the nature and degree of class and race segregation that can negatively impact the healthcare delivery system.

As research by Nilanjan Patra and others such as Nandi and Schneider or Bipasha Maity demonstrates, caste and tribe attributes (belonging to marginalized castes or tribes) form some of the most relevant social determinants of health in India and as such, this project found it wise to conduct a survey of the most basic form of healthcare infrastructure in India that is the Accredited Social Health Activist (ASHA) programme of the Government of India - which form the backbone of the healthcare system in rural India.

An ASHA, Accredited Social Health Activist, is a woman who is selected by a community and is trained, deployed, and supported to improve the health status of that community by securing their access to healthcare services.

Her job responsibilities are three-fold, including the role of a link-worker, that of a community health worker and of a health activist. Some of their specific tasks include bringing children to immunization clinics, treating basic illness and injury, and improving village sanitation. Till date approximately 8,59,000 ASHA workers have been trained and deployed across the country.

Though ASHAs are deployed nationally, their tasks vary by region (usually by state) depending on each region’s needs and existing infrastructure (in the form of other CHW programs like Anganwadis and ANMs). Under the current COVID-19 immunization programs, ASHAs were one of the first to receive the vaccine and have already been trained to vaccinate the population.

The coverage by ASHA workers also varies across the country. The following map will provide some indication as to the spread of ASHA workers across India.

Percentage of women reporting receiving services from an ASHA among all women who had a live birth since 2005

However, while ASHA workers are deployed across the length and breadth of the country, caste and tribe attributes continue to be a factor in some areas of the country while not in other regions.

Some of the main points of our research survey regarding the role of caste and tribe attributes and coverage by ASHA programmes are listed below:

  • Studies in Andhra Pradesh and Uttar Pradesh focussing on Dalit perception of the neutrality of ASHA(s) revealed that many Dalits feel that they are treated unfairly and that their issues are not given primacy. Though there is no hint of dalits being considered ‘naturally immune’ due to their ‘impurity,’ which goes to show that caste operates in its usual multifaceted ways when it comes to its interface with the healthcare system:

  • Some non-Dalit ASHA(s) refuse to go into Dalit houses to do their regular checks.

  • Even non-discriminating ASHA(s) tend to focus their activities more on the upper castes as

  • Upper castes are easier to access as they reside within the village.

  • Upper castes wield power and can question ASHA(s) and hold them accountable in case of lapses or lack of coverage.

  • Some ASHA(s) expressed their contempt for Dalits as they are relatively uneducated and fail to grasp medical instructions easily and “do not have the manners,” or simply, do not come off as polite.

  • While a minority of only 25% of the respondents from the Dalit community said that VHSC (Village Health and Sanitation Committee – which governs ASHAs) gives importance to Dalit issues, a majority (63.33%) of the VHSC members said that importance is given to the Dalit issues.

  • This can be attributed to slightly different priorities of the different castes.

  • Though VHSC(s) have SC, ST and women representation, there is a strong influence of the village sarpanch which often leads to upper caste interests being prioritized.

  • Dalits also seem to have a knowledge gap – people are not adequately aware of the VHSC itself, which indicates the poor quality of outreach.

  • However, a national study on ASHAs concluded that “In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backward castes, had the highest odds of receiving ASHA services.”

  • However, within clusters with an active ASHA, odds of reporting ASHA services declined steadily with increasing wealth status—nationally, in rural areas, and in high-focus states. Therefore, ASHA services being primarily received by SCs and STs is not a big surprise.

  • While the ASHA program had the highest reach in the poorest of populations, it does not address the disparities in the utilization of services across women from different socioeconomic and caste groups, especially the Scheduled Tribes.

  • The culture of many such communities and customs around childbirth make linkages to the healthcare system challenging.

  • A study in Karnataka found that the sociodemographic profiles of ASHAs were in consonance with what was originally envisaged at the initiation of the programme, i.e., ASHA’s were broadly representative of the rural populations from which they were drawn in terms of religion, caste, and occupation.

  • Upper caste women might not be particularly inclined to become ASHAs as it includes association with childbirth which is deemed ‘polluting’.

However, in terms of ASHA work, as well as healthcare reach across marginalized communities in India, not all populations and/or workers’ stories conform to the picture painted in these data points. In order to get a close view of the perception of ASHA workers, we interviewed two ASHA workers, and members of the Namashudra community in West Bengal. The interviews are enclosed as follows:

Case Study 1: ASHA Workers from Andhra Pradesh

Interview 1

  1. Tell us about ASHAs

The ASHA programme started in 2005 under the NRHM (National Rural Health Mission) to improve health care for the needy people. ASHAs are intermediaries between the government health departments and people in need of government health services.

  1. Can you tell us about the ASHA hierarchy?

Each Sachivalayam has one ASHA and an ANM. ASHAs work on the field to conduct surveys and generate awareness among the people while ANM’s, who are more academically qualified are authorised to administer vaccines, injections and advise ASHAs. A group of Sachivalayams come under a PHC (Primary Health Centre) or an Urban Welfare Centre, which, in turn, come under the DMHO (District Medical Health Officer).

  1. What do ASHAs do?

ASHAs work has changed over the years. With COVID 19, we have lots of work to do, filling up vaccines and helping ANMs administer them. When things are normal, each ASHA is mapped to a certain area and is given the responsibility of maintaining the health of that area. So, we initially do surveys on how many people are there in each household, the number of people with communicable diseases, the number of people with Hypertension or diabetes etc. Our most important work is to take care of pregnant mothers and children. We need to go to each house, talk to families about the health schemes and persuade them to take action. We also give them medications and suggest hospitals or doctors to consult. For example, many people do not know that a child needs to be given a vaccine, we reach out to them and convey them the importance of vaccination and guide them to vaccine centres. We also keep in mind their economic situation and ensure that they do not waste money unnecessarily going to private hospitals when they can avail government services.

  1. What does your survey information contain? Does it have information about income, gender, caste?

No, the survey only has medical information. It is very important as sometimes officials may ask for the data all of a sudden.

  1. Who allots ASHAs areas?

Hospitals and PHCs. It depends on the size of the area and how many people in that area need it.

  1. Does Caste play any role in doing your work?

No, it doesn’t.

  1. Does Caste indirectly play a role or hinder any process? Do all castes get equal treatment?

No, caste doesn’t play any role in our work. Yes, our primary goal is to reach to the poorest of the poor who have no awareness, caste has no bearing on our jobs. In fact, we are encouraged to help the most backward of people.

  1. Do any households avoid ASHA intervention? Do you think caste has a role here?

Yes, around 30% of households deny our services, but it has nothing to do with caste. These are richer people or government employees who look down upon government services.

  1. Is there any caste consciousness within the ASHA workforce? How are ASHAs selected?

No, at least from my experience. Initially, one just had to apply to become an ASHA and one would get it. However, over the past few years, we have educated people coming as ASHAs too. Because of increased demand, they conduct examinations.

  1. Are there any reservations in selection?

No. Only candidates with prior experience are given preference.

Interview 2

  1. Tell us about ASHAs

ASHAs are volunteer health workers whose duty is to ensure that all the families allotted to them avail health services and gain awareness.

  1. Can you describe what you usually do as an ASHA?

I go to houses, ask people for their health status, advise them on taking medicines, give them medicines, take them to hospitals, stay beside pregnant women during pregnancy, counsel them and make them understand issues about health. It is upto each ASHA how dedicated she wants to be. Some ASHAs just go and give medicines think that their work is done. But dedicated people become part of the community, gain peoples trust and act as leaders for public health. They convince people not to stay negligent and resolve people’s problems around health.

  1. Is there no oversight over ASHAs?

ASHAs structure changed so much. During the early years when I joined, anyone can become an ASHA and being a voluntary worker, work was limited and official were not too much involved. However, thigs changed over time. Jagan came and increased our salaries, however, along with that they have increased workload and ask us to do many other things like taking people to hospitals and implementing new schemes. Officials have a closer tab on us now.

  1. During your experience, have you ever felt the influence of caste – casteism shown by ASHAs or caste based outcomes?

No, no body keeps caste in mind. All ASHAs only look to serve the neediest. Sure, people are different and some areas have more people of a caste, but that does not matter.

  1. Have you seen any casteism within public health administration?

No, they never talk about caste with relation to work.

  1. Do you think the case might be different in rural areas?

Yes, it could be. Vijayawada is a developed place. There might be discrimination in village areas.

  1. What is the caste composition of ASHAs?

Many of them are OBCs are SCs.

  1. Do you have ASHAs from upper castes.

Yes, but very few.

  1. Are ASHAs not allowed into any houses or people reject ASHA entry/

We don’t deal much with richer people who can afford private services and they also are not very welcoming of us.

  1. Does ASHA serve its purpose and do welfare for the neediest people?

Yes, I think ASHA is very important. We are the grassroots people who ensure public health. Throughout my experience, no ASHA has discriminated people on caste per my knowledge. We always look to help the most underprivileged people.

Case Study 2: Interview among the Matua Community

The experience of the COVID-19 pandemic is an experience of isolation. Across nations, cultures and identities, we come across a ubiquitous notion about “touch starvation” (Pierce, 2020) or “touch hunger” (Mortenson Burnside, 1973) such that touch itself becomes a determinant of space segregation. The lesser known Matua community – with its own history of displacement and untouchability – has endured the effects of the pandemic as a population untouched. I have tried to develop this connotation of touch – both in the medical and the social sensibilities of the term - as I interviewed Matua devotees and political leaders during the pandemic.

The Matua community ushered in nineteenth century East Bengal (now Bangladesh) as a derivative of Vaishnava devotionalism. With a strong political motivation, this religious movement was primarily built on the upliftment of the lower-caste Namashudra people. Deeply interiorising materially-relevant philosophies – bastubaad – the founding saints, Harichand Thakur and Guruchand Thakur, emphasized the dignity of perseverance, communal unity and education. However, with the Partition of undivided Bengal in 1947, the consolidation of this religious group was met with the crisis of dispersion, displacement and isolation. Having been historically exposed to a matrix of migration and refuge, the Matuas have internally generated an ethos of sonic togetherness. Sometimes, in the form of kirtan (singing in praise of the Lord while crying and hugging each other) or collective chanting of Haribol (uttering Lord Hari’s name) or performing matam (a ritual dance that is known to enhance spiritual and physical strength), the Matuas believe in sonic healing; untouchability is confronted with the touch of sacred sound. The dirty, filthy asprishya Namashudra is thus, able to generate a touching interiority that reverberates with sound and is immune to the evils of untouchability.

In my interviews with the Matuas - first with a political leader who holds an administrative post in Tehatta village, Nadia district in India and second, with a music practitioner and school headmaster from Gopalganj village in Bangladesh – I try to look into the perceptions of coping mechanisms with the virus versus the actual realities that inform the rhetoric of healing amongst the Matuas. Animesh Bala, a Central Government employee (Indian Railway) and also, the General Secretary of Nadia district (North) under All India Matua Mahashangha, informs me about the practical resolutions and measures that were adopted to combat the spread of the COVID-19 pathogen. As an administrative head, he ensured the distribution of masks, sanitisers and restricted community-interaction. His group members also helped the local villagers in commuting between hospitals. However, against the background of this medical urgency, he also mentioned that the Matuas across the country were being summoned to demand for their citizenship rights. The organization had scheduled a line-up of continuous marches and rallies in various parts of the country. I also learnt about the ripple-effects that these episodic marches would have in the then upcoming 2021 elections. To overcome the perils of untouchability, the Matuas had to be in touch to pursue their political goals.

Despite the severity of the political thrust, my second interviewee, Masterda from Bangladesh, responded to the religious concessions that the COVID-19 pandemic had brought about. With the annual pilgrimage to the guru’s homeland, the mahotsab, canceled, the Matua bhaktas suffered from a lack of tangible sense of togetherness. In this light, they devised newer strategies to perpetuate communal unity by taking to social media platforms, singing kirtan on video calls and imparting diksha online by gosains (spiritual leaders). In addition, the Matuas were prescribed to perform the rigorous matam to ensure physical strength, and at the same time, invoke an enlightened state of ecstatic devotion. According to my respondent’s understanding, rural Matuas are hard-working and develop stronger immune systems. The chanting of the seminal religious text, Harililamrito, is also said to have helped Matuas get rid of epidemics like cholera in the past. Practical solutions to not contract the virus also included prescriptions of herbs and various concoctions like a pinch of the Thakurbari soil mixed with water. This tricky interface between the scientific and the religious, often indistinguishable, unfolds a plethora of meanings.

Lorea (2020: 241) states, “The religious and cultural identity provided by Matua doctrines, rituals, and narrative repertoires has united Bengali refugees and their descendants, offering a source of dignity, status, and symbolic capital.” We see how even during the isolating experience of the pandemic, Matuas maintain an ethos of unity through politics, religion and practical modes of survival. As a religion that heavily relies on communal congregation as a mode of self-assertion, doing religion online serves as an emerging sense of togetherness. In this sense, the internal dynamic to remain in touch with one another stands as an essential prerequisite to confront histories of displacement, migration and untouchability. On one hand, we see the contagious sacred sound and the physically-uplifting matam while on the other, we see the creation of online islands (in the form of groups and pages) that discuss, practice and rehearse Matua rituals. The rhetoric of the hardworking, matam-performing body is particularly interesting because it reveals how untouch that inheres in the Matua body, comes to be circumvented as an immune body. Because they are untouched, their collective isolation – a paradoxical phrase in itself – helps them to inculcate haptic sensibilities within, while still remaining an untouched space altogether from the outside. In this sense, healing is understood as an interiorised process – through religion, hard-work and the politics of pragmatism. Healing is from within, spiritually and politically, such that the external, impure contagion of non-touch and by extension the virus, is replaced by the sacred contagion of religion, sound and communal unity.

By Way of a Conclusion

The most basic and preliminary conclusion that can be derived from this report is that caste and tribe attributes as well as cultural practices to continue to play a major role in the healthcare delivery system of India, which perversely affects the net healthcare system and continues to permit the proliferation of magical and charismatic / alternative medicinal systems even today - perhaps becoming stronger and more ever present in the course of the nCovid-19 pandemic as is observed in the case of the Matua community of West Bengal.

It is also interesting to observe the nearly diametrically opposite opinions of members belonging to marginalized castes and healthcare workers when talking about the healthcare system and its efficient delivery in India. As it is difficult to assume a gross variation when it comes to the degree of casteism across India, Dalit perception of ASHA programmes and ASHA workers’ perception of Dalit coverage provides interesting avenues of research into the generally invisible nature of caste and tribe attributes when it comes to the execution of government programmes. The summary rejection of ASHA workers when facing the possibility of caste involvement in the delivery system therefore raises interesting questions as to the degree to which caste differences and caste sensibilities even feature in the minds of healthcare activists.

While this report found no inherent notion of Dalits being naturally polluted and/or immune to contagion, the emergency of magical therapeutic modes among certain specific communities does hint at the existence of notions of alternative biologies that may or may not translate into such ideas of natural purity or pollution. Further research along ethnographic and blanket survey lines is needed in this regard.

Finally, while this study attempts to provide geographically diverse data and conclusions drawn from a variety of marginalized communities, the data explicitly drawn from tribal communities is relatively slim - which may be significant as notions of tribal pollution, coupled with the difficulty of reaching several tribal tracts may effectively cause schisms in the already fissured and hegemonized healthcare delivery system of contemporary India.


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  4. Communitisation of Health Services among Dalit Community

  5. Public Report on Health: Some Key Findings and Policy Recommendations

  6. The impact of India’s accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study

  7. Casteism Among Indian Doctors: A Critical Review

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  9. Social identity and perceptions about health care service provisioning by and for the Dalits in India

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  11. District Medical and Health Department | Krishna District, Government of Andhra Pradesh | India


  • Loosely translates to ‘Village Secretariat’, i.e., ward level government body run by volunteers that deals with delivery of public services and schemes. It is a step taken by the YSRCP government towards decentralised governance

  • Auxiliary Nursing Midwife. ANMs need to complete a diploma and qualify an exam to be appointed. They usually have prior experience in nursing and basic healthcare.

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