Nurses—Making a Difference in Global Health

Nurse Stories: Eradicate extreme poverty and hunger

Helping lift the burden of poverty: Teaching first aid to the Dalits of rural India

Each graduate of the first-aid course for Dalits received a certificate of completion, a first responders kit and a widely used textbook titled Where There Is No Doctor.

By Susan C. Benedict, CRNA, DSN, FAAN

Each graduate of the first-aid course for Dalits received a certificate of completion, a first responders kit and a widely used textbook titled Where There Is No Doctor. Like many Americans, I thought Gandhi had eradicated India’s Untouchables caste years ago. Unfortunately, although “untouchability” was abolished by law in 1955, it is very much alive in the rural areas of the southern Indian state of Tamil Nadu and governs almost every aspect of life. The caste system is a socioeconomic tradition of placing people into hereditary categories. It is thought to have originated around 1500 B.C. as a means for prescribing economic and social order based upon occupation.

Although there are many thousands of subcastes, there are four major castes: Brahmins, who were priests and spiritual guides; Kshatriya, who were soldiers and nobility, including princes and kings; Vaishya, who were merchants and farmers; and Shudra, who were manual laborers, masons and providers of services. Ranking even lower than the Shudra were the “outcastes” or “untouchables,” now known as Dalits or, as Gandhi called them, Harijan or “Children of God.” In India, Dalits are also euphemistically referred to as Scheduled Castes. Because one is born into a caste, it endures for a lifetime. There is nothing one can do to escape.

For more than 3,500 years, Dalits were unable to get an education or own property. Their jobs were those considered “unclean,” in that they were associated in some way with death. For example, all cobblers were Dalits because they worked with leather, the skin of dead animals. One subset of Dalits is the Pariahs, the “drum-beaters.” The association with animal hides covering drums placed Pariahs in the Dalit category, and it is Pariahs who beat the drums that lead funeral processions.

There are approximately 240 million Dalits in India, a number equal to about 90 percent of the population of the United States and one-quarter of the population of India (Dalit Solidarity, 2004). The majority work as day laborers in agriculture or in menial jobs such as digging graves, disposing of dead animals, cleaning latrines of human waste and washing clothes at the streams. Day laborers earn 25 to 50 cents per day. Because of hundreds of years of poverty and menial—often degrading—work, the Dalits were thought to be ritually unclean and “polluting” to anyone or anything coming in contact with them.

In the rural areas of Tamil Nadu, caste still governs most aspects of life. Approximately 98 percent of marriages are arranged, and one is expected to marry within caste or face a life of discrimination and often exile. Some villages are exclusively populated by one caste. In mixed-caste villages and towns, the Dalits are expected to live in a separate area. They are often forbidden from using the village well and are made to travel far to carry water. Discrimination against Dalits is overt. At teahouses, Dalits are served with disposable cups, whereas members of other castes are served with china.

Violence against Dalits, including rape of Dalit women by upper caste men, is common and usually goes unpunished. It is estimated that every hour, two Dalits are assaulted and every day, three Dalit women are raped, two Dalit homes are burned and two Dalits are murdered. According to Dalit Solidarity, an organization advocating for rights and improved living conditions for Dalits, the following are frequent:

In upper caste homes, many of the servants are Dalits. After the servant has cleaned the rooms and dishes, one of the family members must sprinkle “holy” water to purify all that has been touched by that servant.

Many Dalits are not allowed to wear shoes. If they do so, they must remove them when they meet a higher caste person.

Often Dalits are not allowed to sit at the bus stop. They must stand and wait until all upper caste people have boarded the bus.

Even if seats on the bus are vacant, Dalits should not sit in them. Even educated Dalits may not be free to own a home or rent where they choose.

Most Hindus will avoid having a Dalit prepare their food for fear of becoming “polluted.”

Dalits may be refused entry into temples or forced to sit in segregated areas in churches.

In recent years, the Indian government has taken steps to improve the lives of Dalits. There is an affirmative action plan in place, allocating a percentage of university positions to members of this caste. However, because most Dalits are so desperately poor, even today, it is impossible for them to meet university entrance requirements and reserved seats go unfilled. The literacy rate for Dalit girls is about 10 percent and that of boys 31 percent (Muthumary, 2004). Government employment has a set-aside of positions for Dalits and the lower castes.

Health care for the indigent is provided by the government at ambulatory care centers and hospitals. Unfortunately, like much of India, hospitals and clinics have been permeated by the bribery system. One must bribe the guard to be let onto the hospital grounds, bribe the physician to be seen and bribe the nurse to receive medicine.

The government hospital we visited was comprised of about six to eight buildings. People live on the hospital grounds, along with goats, cows and pigs. Long lines of people wait to be seen by physicians or to receive medicines. For these reasons, most avoid going to the government hospital. For more affluent patients, there are private hospitals. Some of these are owned by individual physicians, and others are run by religious groups or universities. Care in some is reported to be excellent and inexpensive.

On my first visit to the area, I was accompanied by two graduate students in nursing from the Medical University of South Carolina, as well as a high school student. For four weeks, we would be working in a clinic—St. Mary’s Health Centre—in a rural area of Tamil Nadu.

I first learned of St. Mary’s while preparing for a class on India in a Global Health course that is part of our PhD program in nursing. The clinic was started by a Catholic priest, Father Benjamin Chinnappan, of Camp Hill, Pa. Father Ben is a Dalit fortunate enough to receive an education. He eventually became a hospital chaplain in the United States. The clinic he founded is equipped to provide ambulatory care and deliveries and is staffed by two physicians in the morning and nurses in the afternoon. The clinic also includes a small laboratory and pharmacy. Care at St. Mary’s is free and open to all people, regardless of caste. However, because of its location, the overwhelming majority of patients are Dalits.

St. Mary’s is new and clean and the equipment basic but adequate. There are two treatment rooms, a labor and delivery room, and several offices. There is a large guest room where the four of us stayed. In addition to our other luggage, we brought several suitcases full of over-the-counter medicines, including vitamins, ibuprofen, antidiarrheal medicine and antibiotic ointment.

"Discrimination against Dalits is overt. At teahouses, Dalits are served with disposable cups, whereas members of other castes are served with china." — Susan C. Benedict

Our days were spent seeing patients in the mornings and doing “medical camps” in the afternoons, when clinic staff members go to a village and provide free primary care to anyone requesting it. A van, borrowed from a nearby agency, provided transportation for the four of us, in addition to the two nurses, physicians, pharmacist, and administrators. Our medical camp had been announced several days in advance in the villages we visited, and we were met with lines of several hundred villagers seeking some type of treatment. Often, we set up three or four small tables with chairs. Accompanying the students and me was a translator. Our only equipment was a flashlight, a mercury thermometer, a stethoscope and an old blood-pressure cuff. The pharmacist set up his station nearby.

Many of those we treated were children, often unaccompanied by an adult. In India, one does not need parental permission to receive treatment. Most of these children had colds and sore throats, which we treated with decongestants and lozenges. Many adults had skin infections or rashes. There were also many cases of leprosy, but all of them were receiving ongoing treatment at community health centers.

Another common problem was cataracts. These people were referred to the government hospital. Surprising to us was the prevalence of diabetes. Among the poor, obesity is rare and hard physical labor is common. According to recent data, however, the prevalence of diabetes in rural southern India rose from 2.4 percent to 6.4 percent within 14 years (Ramachandran, 2005). All of the people who sought treatment in the medical camps were Dalits, and most were employed as day laborers in agriculture or in a local brick factory. Child labor is common. Children as young as 6 years of age work in the brick factories, and many are injured in accidents. Unfortunately, it is often a child’s salary that enables a family to eat. Education is not mandatory and many Dalit children work to support the family, thus guaranteeing the continuation of the cycle of poverty.

Other than medical camps, the people in these remote villages have no access to health care because of the bribery system and lack of transportation. Ambulance service is not available. When someone becomes seriously ill or is injured, he or she is carried on a handmade stretcher to the nearest facility. If money is available for a bribe, the person is admitted. If not, the family may beg for money or, as sometimes happens, the person will die outside the hospital grounds.

Transportation is a huge barrier, because no one in the villages owns a car and few own bicycles. The alternative is a bullock cart, but superstition often renders this impossible. If a person were to die in the bullock cart, the cart would never be used again. At the conclusion of our stay, the village elders asked us if we could raise about $10,000 USD to purchase an ambulance for them. It didn’t need to be elaborate, just a four-wheel drive vehicle with the back seats removed.

Since my first visit to India about three years ago, I have returned two more times. Aware of the dire need for emergency transportation in the villages, I decided we should train two people from each village to be “first responders” for emergencies.

The administrator of St. Mary’s Health Centre interviewed candidates and selected a man and a woman from each of 29 Dalit villages. These individuals agreed to accept no payment for their services, to dispense the supplies we provided at no charge and to attend monthly follow-up meetings. Our two-day course, held outdoors at St. Mary’s, provided CPR training and addressed treatment of fever, diarrhea, choking and snakebites. At the conclusion of the course, each first responder received a comprehensive first-aid kit and a textbook in Tamil, Where There Is No Doctor, widely used in remote areas.

Our third visit was already scheduled when the tsunami hit the area in late December 2004. We arrived shortly thereafter with 32 crates of medical supplies. The latter portion of this visit included, in addition to a refresher course for the first responders, an abbreviated two-hour course in home first aid that was taught in five additional villages. To each attendee, a small home first-aid kit was given.

To date, the initial cohort of first responders continues to meet monthly with the staff of St. Mary’s and each gives an account of the treatments he has provided. They also bring their first-aid kits for inventory and replenishment. Over time, a small supply of non-prescription medicines such as pediatric acetaminophen has been added to the kits.

The Dalits of Tamil Nadu continue to struggle economically, socially and physically within a system they cannot escape. Against such formidable odds, our contributions seem insignificant by comparison, and it is tempting sometimes to question whether our efforts are making any real difference. That’s when I’m reminded of what a villager who attended one of our first-responder training camps told us after receiving his certificate of completion: “You have lifted the burden of poverty from our hearts.”

Susan C. Benedict, CRNA, DSN, FAAN, is professor of nursing at Medical University of South Carolina in Charleston, S.C.

RNL - Reflections on Nursing Leadership - Published 3/3/2006 , Vol. 32 No. 1