A peer-reviewed study has found that a significant section of people among healthcare providers hold biases against patients from Scheduled Caste (SC) communities, making them victims of structural inequality in resource-constrained institutional settings. According to the study, over 60% of the healthcare providers who were surveyed expressed explicit opposition to affirmative action policies for people belonging to Dalit communities and 75% of those who took a psychological test showed an automatic, subconscious preference for upper castes. The study, published in the journal Health Care Analysis and conducted by Shivani Yadav of Delhi Technological University and Krishna Ram of Ambedkar University Delhi, does not establish that healthcare providers specifically discriminate against their SC patients. Rather, it shows how attitudes and subconscious behaviours translate to the way patients from marginalised communities are perceived and handled in healthcare institutions. “Against that backdrop, we’ve tried to probe the other side in our study – the attitudes of healthcare providers,” Yadav, the study’s lead author, told The Telegraph. The sample size of 106 providers for the survey included ward boys, nurses, pharmacists, lab technicians, interns, and doctors. By caste, 26 belonged to SC communities, 46 to Other Backward Classes (OBC), and 34 to the General category (GC). Muslim providers constituted approximately 3.8% of the sample. Although the research is based on a relatively small sample of healthcare providers across all eight blocks of Etawah district in Uttar Pradesh, the findings signal a caste-linked bias among them. Data was collected through two measures, the first being explicit measures, with structured questionnaires asking direct questions about their views on reservation policies in hiring and promotion, as well as their comfort with inter-caste marriages and sharing neighbourhoods with people from Dalit communities. Secondly, implicit measures were used through Implicit Association Test (IAT), a validated psychological test that measures automatic associations individuals may be unwilling or unable to consciously report and beliefs arising from automatic social associations formed through experience and social conditioning.88.2% respondents from General castes opposed reservationAmong GC providers, 88.2% opposed reservation for people belonging to Dalit communities and an equal share believed a GC individual would likely lose a job to a less qualified SC or ST candidate. Among OBC providers, 47.8% opposed reservation, while only 7.7% of the SC respondents opposed reservation. Opposition among non-SC groups was routinely framed as a merit argument, with providers saying things like “they score minimum and get seats in colleges and secure jobs without studying or working hard.” One cardiac specialist, a Brahmin doctor from the GC, showed a peek into the attitudes the study has underlined, defending traditional occupational caste divisions as rooted in individual capability. “A ‘Vaidya’ would heal, a rag picker would pick up rags, a kshatriya would perform in war,” he said. “Now Britishers tried to provoke – they asked SC people to cure the sick, to fly airplanes, and see what happened then.” This sense of entitlement was further apparent when, upon being asked about his social group he responded: “Can’t you figure out from my name? Mishra is what? We are Brahmins.” Beyond reservation, the study measured social distance by asking non-SC providers whether they would support a close relative marrying a person belonging to a Dalit community or living in a neighbourhood where half the residents were from Dalit communities. Around 55.9% of GC respondents and 43.5% of OBC respondents opposed inter-caste marriage with a someone belonging to a Dalit community. Around 30% of OBC respondents and 20% of GC respondents opposed living in a neighbourhood with a majority of residents from Dalit communities, citing “discomfort”, “hygiene issues with people belonging to Dalit communities”, and “preservation of Brahminical supremacy.” The study also found that 23 healthcare providers from OBC and GC also alleged that people belonging to Dalit communities experience poorer health because of inherited susceptibility to disease. Of the 106 providers, 48 completed the IAT. Of them, 75% or 36 out of 48, demonstrated an automatic preference for Forward Castes over SCs. All 16 GC providers who completed the IAT showed this preference, as did 76.5% of OBC providers. Among SC providers, 46.66% showed automatic preference for Forward Castes, while the remaining were split between no preference and a preference for Scheduled Castes. These results in the implicit test establish the same caste hierarchy which was visible in explicit measures. Kumaraswamy Thangaraj, a genome science researcher at Centre for Cellular and Molecular Biology (CCMB), Hyderabad, who was not involved in the study, cautioned, “endogamy and social isolation can facilitate the concentration of genes and inherited disorders, but that does not mean caste itself determines genetic susceptibility to disease.” ‘Reflected indirectly in actions and attitudes’A psychiatrist told the researchers that in clinical settings, discrimination rarely shows up overtly because providers know its repercussions, highlighting how caste attitudes are manifested. “These things exist and are reflected indirectly in actions and attitudes, the way people respect and behave with some people…People from underprivileged sections face poor treatment from hospital staff, sometimes from doctors, but mostly from ward boys, nurses, inquiry people” he said.A doctor from an SC community working at a Community Health Centre (CHC) said: “Of course, discrimination happens in healthcare, at all the levels. It’s not just the case with nurses or ward boys, even doctors tend to hold negative attitudes and behave differently with different people. I have heard my colleagues posted at PHCs (Primary Healthcare Centres) and CHCs say things like, ‘It’s not a good place, mostly Bhangis and Chamars (Words used as casteist slurs against people from Dalit communities by upper-caste people) come there.'” The survey found that healthcare providers belong to SC communities were more likely to acknowledge caste-based discrimination than non-SC providers, who either dismissed or denied its presence in the society. Ashwini Deshpande, an economist at Ashoka University in Sonipat, who was not associated with the study, told The Telegraph that although this research could shed light upon caste hierarchies, a single-district sample limits how broadly the conclusions can be generalised. In 2006, Shah et al., in a study across 17 districts in Andhra Pradesh, Bihar, Tamil Nadu, and Uttar Pradesh, documented untouchability practices in government health facilities including restricted entry into PHCs, discriminatory treatment by medical staff, and the charging of fees for services that should have been provided free. An earlier study by Sanghamitra Acharya at Jawaharlal Nehru University found that 69% of children belonging to Dalit communities surveyed in Gujarat and Rajasthan said doctors did not touch them, while 91% said lab technicians made them wait longer. Further, an Oxfam India report from 2021 also highlights that one-third of Muslims and one in five of people belonging to Dalit communities and Adivasis experienced discrimination at healthcare facilities or by healthcare professionals. Lastly, the researchers have also been careful about the limitations of their findings and urged the readers to look at their study from three methodological limitations. Firstly, it draws on a small sample from a single district in Uttar Pradesh, which limits how broadly its findings can be applied. Secondly, it does not examine how caste intersects with other social identities such as religion and gender. Muslims were under-represented in the sample. Thirdly, the IAT results should be read as measures of automatic social association rather than direct evidence of discriminatory behaviour in practice, and explicit responses on sensitive topics may have been shaped by social desirability. The test was also administered only in English, excluding some staff. The researchers suggest a Hindi-language caste IAT would improve future research. Ramsha Sartaj is an editorial intern at The Wire.