A recent podcast by JAMA addressing structural racism sparked a widespread outrage among the medical community in America. India is one of the most religiously and ethnically diverse nations in the world. While not divided by race, the country is deeply divided by caste, culture, language, regionalism, and sexism. We want to highlight the structural discrimination amongst the medical fraternity in India, beyond racism. In fact it includes all kinds of discrimination based on a deep-rooted assumption associating superficial physical differences and social standing with intellectual qualities. In the practice of medicine, in order to treat a disease we must first understand its etiology and pathogenesis. Social discrimination is no different, explicit recognition is an essential step in elimination of disparities.
Racial-inequality in America has its parallel in caste-inequality in India. While highly educated people of medical community might not indulge in abhorrent practices such as untouchability, resentment against doctors of certain castes likely stems from several factors such as sense of caste prestige, caste endogamy, and belief in religious dogmas. These factors are entrenched in the minds from the very beginning, and continually reinforced over the generations. Evidence indicates that caste-based discrimination permeates the medical community. Students of certain castes and tribes face systematic denigration in medical institutions. Though seemingly subtle, the impact can be tremendous on the lives of doctors from marginalized communities, at various stages of their careers. Few incidences of students facing caste-based discrimination in medical colleges have been reported and an affirmative action against caste-based discrimination is long awaited. The sensitive nature of this topic makes gathering evidence or conducting independent investigation extremely difficult. Asseveration of this ingrained history and ongoing harm is essential in order to constructively engage in changing and actively dismantling the status quo.
Although an increasing awareness and public outcry has brought upon a stage of conscious incompetence regarding caste-based discrimination, regionalism amongst medical community is far less discussed, and perhaps has even wider implications in modern societies. Regionalism in India roots from the multifarious diversity of languages, cultures, ethnic groups, communities, religions, and so on. This sentiment is fortified by the regional conglomeration of these identity markers, and heightened by a sense of regional deprivation. Several challenges are faced by a young medical student opting to study in a far-off Indian state, including but not limited to cultural and linguistic barriers limiting interaction with teachers, colleagues, and patients. The resulting social isolation along with the workload and academic struggles of a residency undeniably take a toll on their mental health.
While underrepresentation of women among leadership positions in medicine is well documented, the prejudice associated with gender stereotypes can be real. Female doctors are customarily expected to be less assertive and less competent than their male counterparts. Female residents are far more likely to be recognized as nurses than male residents. The implicit insult in the notion that a woman wearing a white coat couldn't possibly have gone through the rigorous training required to become a doctor is offensive. While number of female residents in medical institutions has been steadily rising, the discrimination reminds us of a gender gap that might not be crossed by simply outnumbering our male counterparts. Gender pay gap exists in nearly every profession, but as per a WHO report, the gap in healthcare is 25% greater than any other occupation. Women form up to 70% of the workforce but occupy merely 25% of the leadership positions, implying that although women deliver the bulk of healthcare globally, men continue to lead it.
Medical community is not immune from homophobia and insensitivity to LGBTQ+ community. Health care workers from these sexual minorities face structural discrimination, and fear of social exclusion and stigma can be significant, especially in the conservative societies such as India. Depathologizing homosexuality has been a long battle that has stretched for decades. Diagnostic and statistical manual (DSM) and International classification of disease (ICD) do not consider homosexuality a mental illness anymore. Several outdated terms are however replete in Indian medical curriculum, homosexual relationships are described as “sexual offences”, transvestism as “sexual perversion” and transgender persons as suffering from “gender identity disorder.” A questionnaire-based study conducted among 290 Indian medical students found that 15.9% of the respondents believed homosexuality to be a mental illness and 24.8% of students considered homosexuals neurotic. A significant number of medical students with negative attitude towards homosexuality emphasizes the need to discontinue usage of these obsolete and socially stigmatizing terms in Indian medical curriculum. Indian medical community has taken a few laudable steps in this direction that must be underscored. A position statement was released by Indian Society of Psychiatry in 2018 categorically stating that “homosexuality is not a disease and must not be regarded as such”. Health Professionals for Queer Indians (HPQI) is a wonderful initiative that bursts myths regarding homosexuality and sensitizes health care staff towards the medical needs of LGBTQ+ community. While societal tolerance towards sexual minorities has improved slowly but steadily, 'coming out' continues to be a difficult decision, with immense personal as well as professional ramifications. Any individual electing to reveal their sexual minority status must be supported, respected and even applauded for their decision, appraising the immense courage necessitated for the same.
To conclude, structural discrimination has multiple faces, and though many-a-times unintentional, has potential to restrict the opportunities for those discriminated. Deep introspection of the inherent socio-cultural biases and prejudices towards people from different cultural identities, and compassion for our peers are the catalysts that will help nurture the thought of diversity, equity, and inclusion. The scale of these problems may sometimes seem overwhelming, but social change can be accomplished through a series of minute steps made by individuals and institutions in pursuit of an improved world. These biases cannot be uprooted by any policy, agenda, norms, or planning. We, as a community, must come forward and unite against all forms of harassment and inequality.
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