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Widespread discrimination against marginalized communities and social groups in India takes a large toll on the overall health of the population.  We at r.i.c.e. seek to understand the impacts of various forms of social hierarchy on child and maternal health in rural India.


Caste identity continues to define hierarchy and status significantly and is an important marker of economic inequality, although not the only one.  Caste hierarchy is neither linear nor fixed, and debates over its changing forms continue; however, there is consensus on which groups constitute the bottom of the system.  Although untouchability is illegal and punishable, overt and covert instances of untouchability, such as violence, abuse, and humiliation, continue to occur; individuals from these castes suffer from the consequences of their “stigmatized ethnic identity” in their daily lives, even when they are not engaged in their traditional roles. It is not surprising that these groups are also disproportionately poor and less educated, with limited access to productive assets or decent employment compared to the upper castes.

In terms of r.i.c.e.’s work on sanitation, we believe that caste hierarchies are a major reason that open defecation has been difficult to eradicate in India. Concepts of “purity” and “pollution” are central to the caste system, and those lowest in the caste hierarchy are considered the most impure.  In the context of sanitation, people feel intense disgust towards the idea of dealing with feces and cleaning latrine pits because feces are considered “unclean” and “impure.”  By extension, those responsible for cleaning feces are considered polluting.  Given enduring caste hierarchies, Dalits, who are often called upon to handle human waste, even though manual scavenging is illegal, are considered polluted because of this work, and people in higher castes consider contact with them to be polluting as well.

Simple latrines, common in most developing countries, are difficult to find in India because they are considered unacceptable, in part because latrine use means accumulating pollution and impurity near the home.  Pit emptying in India presents a deeper challenge than in most societies because of these concepts of purity and pollution and because of caste and untouchability.  Deeply internalized casteism means that most people are unwilling to empty their own or others’ latrine pits, making latrine use a challenge much more complex than generally understood.


There is much documentation and evidence of the many ways in which Indian society discriminates against women, even from a very young age.  One well measured manifestation of this discrimination is the “missing women” phenomenon: in the 2011 census, the under-six sex ratio was just 914 girls per 1000 boys.

Patriarchy and age-hierarchy mean that women have very little autonomy over the course of their lives, including a lack of say in household decisions, a lack of control over household resources, limited access to knowledge and information, an inability to move about freely, a lack of independent decision making power, and general inequity in negotiating relationships within the household.  Women are generally subordinate to men and younger household members are subordinate to older members.

Both men and women alike suffer from an extremely high burden of disease.  But in addition to failed government programs, young women in India have very low social status, and face severe intra-household discrimination, contributing importantly to why pregnant women in India are so unhealthy.    The kinds of investments in pregnancy that improve maternal nutrition, and therefore child health, are limited by strong intra-household hierarchies; many young, pregnant women quite literally eat last.


r.i.c.e. is a non-profit research organization focused on health and well-being in India. Our core focus is on children in rural north India. Our research studies health care at the start of life, sanitation, air pollution, maternal health, social inequality, and other dimensions of population-level social wellbeing.

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