Poverty, poor education, and the re-emergence of caste in India

Date: 07/24/2011


“Poor people are usually very uncivil in their behaviour...... they would have hazy scruples, usually resorting to base activities (theft, crime, rape) to get by....Indians seem to be so used to living in low quality surroundings, they have become low quality people..... poor kids have been allowed to grow into poor adults, and what their value system is like is anyone's guess.... bad civil engineering, slums which are allowed to propagate[SIC], uneducated people being allowed to have a say in the decision making process by allowing them to vote, all have resulted in a society that more resembles a bacterial colony than a human civilization....So it would all have to start with forming a new megacity like bangalore or mumbai in some new place...... Restrict the number of people per square kilometre. NO UNEDUCATED B*******S ALLOWED.”

I blinked in disbelief as I finished the email. I re-read it again to make sure I hadn’t imagined it. No, I was bang on the first time. It wasn’t the first time, neither in my life nor during this trip, that I had come across such sentiments from Indians in my age group. Every time such opinions are aired in my presence, I get a really unpleasant deja vu. I hadn’t been able to place this sense of deja vu until yesterday: this was exactly how I had felt, in the 6th grade, when I had seen a picture of an “untouchable” being beaten to death by members of a so-called-high caste for casting his shadow on their food. Are we about to see the rise of a new type of caste system, one that marginalizes and exploits the poor and the uneducated?

The conditions couldn’t be more favorable! As I mentioned in a previous post, the newfound prosperity of India is limited to a population of about 60 million. Of the remaining 1.14 billion, 638 billion are so poor that they’re forced to defecate outdoors. These two types of Indians live in two distinctly different worlds: while the women in one set plan trips to America and Europe, women in the other plan trips to the fields to at night to defecate with a modicum of privacy. It is easy to imagine, for me at least, how the disgust of one group can be easily matched by the resentment of the other. Indeed, such is the case. I’ve heard poor men complain about the avarice and the immorality of the “big people from big cities” and I’ve encountered disgust at the lifestyle of the poor from my rich friends and a concern that they’re dragging down their quality of life. The poor judge the rich on their abandonment of traditional values whereas the rich make cruel jokes about the poor for their lack of “polish” and finesse (as described by our erstwhile British masters). A frequent complaint I’ve heard is that the poor shouldn’t be allowed to vote because they are uninformed and easily manipulable. This is madness! We’re all citizens of India. Our status as humans is not contingent upon our income or education. We can’t allow our society to be ripped apart like this.

Yes, the differences are steep.

I have written this post to beseech my educated Indian readers to be aware of this us-and-them feeling that is ingrained in Indian society and may lead to another caste-like divide even if it is not called as such. At least in the short term, I don’t see the vast polarities in India changing. We must not let the polarities change us in our approach to the disadvantaged. All this nonsense about the poor being morally corrupt and acclimatized to subhuman living conditions is precisely that-- nonsense. The person who treated me most graciously this summer could not have made more than Rs. 4000 a month ($100), which is really not that much. Embarrassingly, I probably had twice that much money in my wallet when I met him. At one of our community screenings. I mentioned that I was a bit hungry since I had not had breakfast. Traditional Hindus hold the view that guests must be treated like gods. This man, a senior resident of the village, promptly took out his own humble breakfast of idly and sambar and forced me to eat it. I felt horrible taking his food, but he absolutely refused to accept my “no, thank you” or my money. What’s more, he insisted on waiting on me and even helped me wash my hands with water that he had gotten out of a water pump. I know from experience that this is the rule, not the exception. So, please, don’t vilify the poor. They’re more sophisticated than they’re given credit for.

 I don't think it is possible for anyone with the means to read this blogpost to imagine the life of a truly poor individual. Consequently, we have no right to make blanket statements condemning or belittling the poor.

Another frequent accusation about the poor is that they reproduce quickly, put increased pressure on the already limited resources, and increase the congestion. Yes, this is true. A popular theory behind this is that, given the high infant mortality rates among the impoverished, parents decide to have a lot of children so that at least a few are left behind to take care of them when they are old. This has been shown in numerous studies. Children, after all, are the traditional retirement plans for parents in countries like mine. Even my parents, who are not at all poor, think of me as their retirement fund and are counting on me to take care of them when they are unable to do so themselves. Most people approach this population problem in a Malthusian spirit which is incredibly dangerous. History has repeatedly testified that reducing poverty also reduces the fertility rate and the infant morality rate. Dr. Guerrant loves giving the example of New York City which had a higher fertility and mortality rate than present day Bangladesh(2). On the graph below, you can see how they fell with the increased prosperity of New Yorkers. So, if you want to reduce population and congestion, help the poor get out of the poverty trap and keep them healthy. It’s literally the only thing that works.

Note how regions infamous for high mortality inevitably also have a high fertility rate. It is a compensatory dynamic. (2)

One thing that the poor demonstrably do lack is education. This leads to superstitious beliefs and an inability to fully utilize the resources that are available to them. Every extra year of school education, adds about 8% to an individual’s earning capacity(1). Therefore, not being able to receive a complete education is a recipe for remaining poor. Reading Poor Economics by Abhijit Banerjee and Esther Duflo really made me appreciate the things that influence a poor man’s ability and decision to send their children to school. They do so amidst immense hardship. Education is a privilege and if you manage to get a good one, that’s your great good fortune. All the Indians who’ve ever launched into diatribes about our uneducated countrymen went to school in buses. The kids they rip on had to walk many miles to school and not always with shoes. In fact, Gemlyn, one of my coworkers this summer, helped formed an NGO that enhanced school attendance amongst children in remote areas by buying them shoes and hiring auto-rickshaws to carry them to good schools that were 16 kilometres (ten miles) away from their villages.

Unfortunately, even if they get to school, many times the education is terribly sub-par. Sister Eugini, the principal of Auxillium College in Vellore, told me about the horrendous schools in rural Tamil Nadu where the teachers come late, if at all, and refuse to teach. The children spend their time polishing the teacher’s bike instead of their maths skills. The teacher leave the school on seemingly luminous bicycles, leaving behind children who are doomed to a dark academic or economic future. Surprise checks did help a little, but they’re not always possible. Some fundamental changes are needed, but I am not qualified to prescribe any(3).

Yes, crowds can get frustrating in India.

Many of us make these “us-and-them” comments about the poor and uneducated without sufficient thought. I don’t actually think malice lies at the root of it for the most part. Frustration? Perhaps. India is decidedly overcrowded, overcompetitive, and not always clean. People coming back from a sojourn abroad, like the friend who wrote me the email, do suffer from reverse culture shock. I wrote this piece to make them aware of this tendency and how it can lead to fissures and intolerance in our society reminiscent of the abhorrent caste system that still lingers in India like a metastatic cancerous lesion. In conclusion, I’d like to present a Thomas Jefferson quote that I found paraphrased in Dr. Guerrant’s article (2):

“The power of society belongs in the hands of the people. If the people should ever seem in-adequately enlightened to exercise this power, the solution is not to remove the power from the people, but to educate them.’’

I think our work is cut out for us.

----

Disclaimer: The guy who sent me the email is an old friend. I respect him deeply as a scientist, but he has just returned from a very well designed and run European country and is almost certainly in reverse culture shock. Please don’t criticise him in the comments.

Bibliography:

1. Banerjee, AV and Duflo E. Poor Economics. Random House India. 2011
2. R.L. Guerrant Why America Must Care About Tropical Medicine: Threats to Global Health and Security From Tropical Infectious Disease. American Journal of Tropical Medicine and Hygeine. 59 (1) 1998.
3. Personal communication. 07/01/2011

Fixing leaks

Date: 07/10/2011


With my eyes scrunched up and my forehead crinkled, I listened like I had never listened before. The only thing I was aware of, apart from the drop of perspiration slipping slowly down my nose, was the beating of my patient’s heart in my ears. I moved the stethoscope to a different location to confirm my belief that there were no abnormal S3 or S4 sounds. A drop of perspiration fell from my the tip of my nose to the cement floor. I was tempted to take a break and wash my face at the tap outside.

Leaky tap outside the screening venue....fitting imagery for our global health situation?

We were in the midst of another community health screening. Our goal was to provide TLC to the population of the village and draw blood samples to test for the prevalence of Celiac disease in the community. This information is vital to avert an impending epidemic of the disease in India. We were planning to do screenings in two different villages and were expecting about 400 people to come by and ended up being overwhelmed with 500 attendees whom we saw over a course of 10 hours. Kartik, Gemlyn, and I were working as the medical officers. Our work was to quickly elicit a history and prescribe simple medicines ranging from multivitamins to famotidine (an H2 inhibitor to reduce excessive stomach acid production) to ameliorate their suffering. We also referred them to specialists when we realized that we were out of our depth. Suresh and Shrikanth were drawing blood samples, Bala was directing the whole show. Vettri was measuring heights, John and Murugan were drawing in the crowds, and Gowri was helping me with the translations.

Bala being a dynamic leader as usual

You can see how crowded it was getting.

My stethoscope had been repositioned and I was about to re-scrunch my eyes when I noticed the lady’s son staring at me. My eyes scanned his tiny body. I took in his bare feet and his hair which glistened with the coconut oil his mother had put in lovingly. His shirt was buttoned in two places and held in another place by a safety pin. It was only then that I noticed how his shirt was stretching over his distended belly. After another few crinkled and scrunched up seconds, I determined that his mother didn’t have any obviously abnormal heart sounds. She turned to go, but I took the moment to swoop down on the kid. A quick unbuttoning (and un-safety-pin-ing) later, my suspicion was confirmed-- his belly was distended and his limbs were stick thin, a sign of protein energy malnutrition (PEM). With Gowri  translating rapidly, I immediately counseled the mother on the child’s nutrition and gave him a deworming pill (Albendazole, single dose) for good measure. His brother turned out to have the same problem. Fixing PEM early in childhood has been shown to increase the income and productivity of individuals. Abhijit Banerjee and Esther Duflo remind us that Kenyan children who were dewormed for two years earned 20% more than children in schools of equal quality who were only dewormed for one year.  I was immensely pleased to have a crack at this high yield intervention. 

A little girl in the next village. Her prominent pot-belly and stick thin limbs helped me diagnose her protein energy malnutrition from across the street.

A few minutes later, I cautiously pulled a young man’s eyelids down to check for pallor in his conjunctiva which, if present, is indicative of anaemia. I felt my shirt being pulled out of my Jeans. With some irritation, I wheeled around to face the scoundrel perpetrating this sartorial outrage on me. I came face to face with a fourteen month old girl with big brown eyes and half open mouth in her mother’s arms. My irritation morphed into a smile as I greeted the little girl. However, within a few seconds, it was apparent that she too suffered from PEM. My mentor, Dr. Guerrant, had demonstrated that the window of opportunity to do something about malnutrition and the subsequent stunting ended at 2 years. She was 14 months old! I still had the time to fix her trajectory of growth! I did so with great gusto and optimism. Over the course of the day, I did this again and again. Interestingly, many of the parents hadn’t brought the children to be checked and I only caught them because I was looking for signs of malnutrition in the kids. 

This is the sight that greeted me when I spun around in irritation.

Handing the baby back to the mother after inspecting her.

I know I often write very dejectedly and bitterly about global health issues. Even today, I met people I could do nothing for like a gentleman and a lady with severe chronic obstructive pulmonary disorder (COPD). For them, it’s de facto a death sentence because they don’t have the economic means to secure treatment and the public health system is too overwhelmed to subsidize it for them. I see the global health issues our world faces as similar to the leaky tap in some respects. Bit by bit, we lose human capital to stupid and preventable conditions like malnutrition and malaria. It may not seem like a lot, but the drops and the lives being wasted both add up to a burden the world can ill afford. By helping those little children today, I feel I plugged the leak on a nano-scale and I don’t see why we can’t do it on an infinitely larger scale. 

He had severe COPD. I heard the wheezing through my steth and asked Gemlyn to confirm the diagnosis. We couldn't do anything for this poor fellow. He simply cannot afford the Rs. 10000 per month ($750 USD PPP) that are required for the best treatment. Still, sometimes it's important to focus on the good we can do as well as the areas where we feel helpless.