At the end of March, Ambedkarites commemorated the anniversary Babasaheb Ambedkar’s Mahad Satyagraha of 1927 – one of the greatest fights for equality that the framer of India’s Constitution undertook. But the struggle for access to water was not only an attempt to abolish untouchability: for me, this struggle for a vital resource essential for human survival was also a fight to ensure public health for Bahujans.

As we celebrate BR Ambedkar’s 131st birth anniversary, it’s worth recalling that he not only battled for the socio-economic upliftment of a community that was described as untouchable but he was also a fierce public health advocate.

He argued for better budgetary allocation for public health, maternity benefits for female workers and birth control measures to tackle key health challenges faced in the Bombay Province by Bahujans – members of the Scheduled Castes, Scheduled Tribes and other lower-caste communities belonging to any religion or ethnicity.

As any public health champion would, Ambedkar used data to attract the government’s attention to these problems. He urged the provincial government to invest in education, drinking water, and healthcare rather than spending money on prohibition policies aimed at stopping the consumption of liquor. In addition, the roots of India’s occupational health safety measures can be traced back to Ambedkar’s deliberations on labour welfare.

Equality and equity

On his birth anniversary, as they do every year, political parties across the spectrum will reaffirm his idea of equality. However, Ambedkar’s idea of equality cannot be realised without first understanding his concept of equity – ideas that are ignored by India’s new rising populist welfare politics. These policies treat everyone in the same way regardless of their differences and fail to address socially produced, systematic and unjust differences that render certain populations more vulnerable.

As a consequence, these welfare programmes are likely to miss the core challenges faced by Bahujans, especially in public health.

In addition, these policies do not empower communities and merely provide basic subsistence. They are contrary to Ambedkar’s desire to empower communities based on their socio-economic needs rather looking at everyone through the same lens.

Long after Ambedkar’s death, the root problems that hamper Bahujan health have not changed. Bahujans are still fighting socio-economic deprivation and discrimination, stigmatisation, environmental dangers and neglect by the system. Members of the Scheduled Castes, Scheduled Tribes and Muslims have shorter life span than the upper-caste individuals not only because of their poverty and the poor environment they live in. This is also because of the discrimination they face in society.

In 2015-’16, for example, the rate of stunting (impaired growth due to malnutrition) among India’s children under the age of five was nearly 36%. In the same period, the extent of stunting among children from the Scheduled Castes and Scheduled Tribes was 40%. This was worse than the indicators of Sub-Saharan African countries, where the figure stood at 31%. However, only 26% of upper-caste children experienced similar malnourishment.

Pregnant women from the Scheduled Caste and Muslim communities are less likely to utilise antenatal services than other social groups, studies show.Lower-caste individuals receive differential treatment once their caste identity is revealed to the healthcare providers. Muslims face religious discrimination when they go to the hospitals.

The case for Bahujan health

However, since a great many Indians are now living on government assistance and probably suffering from the same diseases, why is there a need to talk about the health challenges of Bahujans separately?

To begin with, Bahujan health challenges are India’s public health challenges. Take the example of malnutrition, child mortality or other health indicators. Despite significant progress, India lags on these health indicators on an international scale. This raises serious concerns about India’s current strategy in tackling public health challenges.

Within the country, Bahujans are disproportionately represented at the lower ends of these health indicators as shown by consecutive National Family Health Surveys . Clearly, the country is less likely to make progress on public health indicators without addressing the health needs of Bahujans.

In addition, it has been recognised that the Covid-19 pandemic has widened health inequities. In the western world, many governments have acknowledged that the pandemic has affected theirlow–income communities the most. Such data in unavailable in India, but it should not take much imagination to understand how caste- and religion-based health disparities have widened during the pandemic.

My own research shows that Bahujans are more reliant on health insurance programmes because of their weaker socio-economic status. However, tertiary hospitals where insurance is applicable are not always within their reach geographically. Further, Bahujans neither can afford private care nor can ignore the overcrowded public healthcare facilities, today.

Moreover, there is not enough representation of Bahujans in the upper echelons of public health policy making to argue for their health. The most prominent Bahujan movement is the Safai Karmachari Andolan, which fights for a respectable and safe work environment for the sewer workers – who are almost uniformly Bahujans. But this movement lacks strong support from public health experts. This is because the health hazards faced by these workers are seen as a problem of a specific community, not as a problem for everyone.

The same is the fate of sickle cell disease, a genetic disorder that leads to anaemia, chronic pain, multisystem failure and eventually death. Nearly 15% of the world’s babies with this condition are born in India. This disorder is mostly present among Adivasis and members of the lower castes: its prevalence reaches 35%-40% of the Scheduled Caste-Scheduled Tribe population in some areas. However, the national level public health efforts to tackle this fatal disease are half-hearted and tribal states are left on their own with limited funding from the Central tribal affairs ministry for the Sickle Cell Disease programme. India is yet to set up a national-level newborn registry that could help in early detection, treatment, and management of the disease.

Tackling disparity

India’s health programmes and policies, including the National Health Policy 2017, do not list concrete steps to tackle caste or religion based health disparities – a prominent health determinant in the country. The world of health promotion now focuses on tackling structural factors such as poverty, racism, gender, and food insecurity that increasee the risk of non-communicable diseases among specific populations. But the guidelines of India’s non-communicable diseases prevention programme still focus on personal risk factors.

The guidelines for the government’s multi-sectoral collaboration for various ministries to tackle such diseases provide only a vague description of how the structural determinants of health will be eliminated or addressed.

This is contrary to international practices. Around the world, governments have taken concrete steps to understand the public health challenges faced by their most vulnerable populations. In the United States, for instance, the health department has established National Institute on Minority Health and Health Disparities. Canada has the Center for Indigenous Health and Determinants of Health.

However, India lacks institutions to specifically investigate the health problems of Bahujans. The 2018 guidelines of the government’s NITI Ayog think tank recommends establishing national-, state- and district-level institutes for Scheduled Castes and Scheduled Tribes. We need these institutes to be up and running soon, with a strong research focus on health disparities. A separate institute to investigate the socio-economic and health challenges faced by religious minorities, especially by the Muslims is also needed.

In addition, while addressing the healthcare needs of tribal populations, greater attention should be paid to the recommendations in 2014 of the High-Level Committee Report on socio-economic, health and educational status of tribal communities of India for the Planning Commission and the report of the expert committee on tribal health the previous year. These reports recommend establishing tribal health councils, addressing social determinants of health such as education, income, water, sanitation, food and conducting specific research on tribal health.

India’s current political discourse will shape its future public health approach as well. While we need a welfare lens to distribute services and public goods evenly, it cannot be at the expense of tackling inequality. In certain situations, as Ambedkar pointed out, “..…what we want is not equality, what we want is equity.….Equality is not necessarily equity….” Public health in India qualifies for this distinction.

Bahujans will have to assert their rights without falling prey to the rampant welfare gimmicks. The provision of health facilities in every neighbourhood may provide some respite in accessing healthcare. But the public health challenges of Bahujans are not only confined to geographical access. They do not feel safe within the current system. They do not feel trusted within the system. They do not feel that policy makers have built trustworthy public health structures or that healthcare workers understand their culture, beliefs and traditions.

Unless and until we build a robust public health system that gives prominence to Bahujan’s health challenges, Ambedkar’s dream of creating a just society will remain unrealised.

Preshit Ambade is a public health policy researcher currently working as a postdoctoral fellow at the Ottawa Hospital Research Institute in Canada.