Indian Journal of Social Psychiatry

INVITED PERSPECTIVE/VIEWPOINT
Year
: 2021  |  Volume : 37  |  Issue : 2  |  Page : 148--151

Social determinants of wellness among medical students


Rama Vaidyanathan Baru 
 Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India

Correspondence Address:
Prof. Rama Vaidyanathan Baru
Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi - 110 017
India

Abstract

The purpose of this piece is to provide a perspective on how societal dynamics and changes in India have a bearing on wellness among medical students. Wellness is a dynamic state that is often analyzed in terms of attributes of emotional, mental, physical, and interpersonal/social at the individual level. However, the societal context plays an important role in determining wellness even at this level. The social determinants of wellness would include the individual's location in the social hierarchy, economic, social, and cultural capital that they have access to, and the aspirations and expectations that are placed by the family, peers, and society at large. While this is common to most college-going students, medicine being an elite profession that enjoys high status and seen as providing social mobility, there is increased pressure in terms of competitiveness and performance. These complex interactions result in many challenges for medical students as they negotiate multiple demands – economic, academic, interpersonal, and societal in an institution for a prolonged period of time.



How to cite this article:
Baru RV. Social determinants of wellness among medical students.Indian J Soc Psychiatry 2021;37:148-151


How to cite this URL:
Baru RV. Social determinants of wellness among medical students. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Oct 17 ];37:148-151
Available from: https://www.indjsp.org/text.asp?2021/37/2/148/320206


Full Text



 Introduction



There has been a growing demand for admission to medical colleges ever since independence in India. Both the scores at the plus two levels and clearing the Joint Entrance Examinations determine the process of entry into medicine. Even on clearing these exams, the ranking determines the admission to a college. This long journey from school to medical college is itself a “project” for both aspirants and their families. The individual and the family make a lot of financial and emotional investment in preparing for admission.[1] Studies have shown how while even in school, a fairly large percentage of aspirants for medicine go for coaching to clear the entrance examinations. The stress that this process produces is also well-documented. It is largely the middle and lower middle classes that form the bulk of the clientele of these coaching centers. The sacrifices that the family makes, both financially and emotionally, are high and as a result, the expectations of returns are equally high. Apart from private coaching while still completing school is one approach, there are several students who take a year off after to focus on preparing for the competitive entrance examination. Over the last three decades there has been an expansion of private coaching centers across states in India that “prepare” students to take the medical entrance. These centers are now organized with hostel facilities with fairly high fees. The curriculum is tedious and requires long hours of classes that have a negative effect on the mental and psychological aspects of individuals. Studies have pointed to fatigue and even burnout due to the inability to cope with the day-to-day pressures of a competitive environment.

 Social Realities in Medical Colleges



A student who gets admission to a medical college has already gone through quite a long and arduous process of work. Once students get admitted they must negotiate an elite institution, which is socially hierarchical and academically demanding. The socioeconomic background of the students determines how they are able to negotiate the institution personally, academically, financially, and socially. As Maurya[2] observes:

”Most of the Dalit students in higher education are the first generation of learners and come from educationally and financially deprived families. As they hardly receive any guidance from their own families and communities, they are mostly dependent on faculty and university administration for educational support and guidance. Also, because of their poor financial background, they find it hard to pay for private tuition or coaching classes and other educational resources that are easily available for students from strong financial backgrounds. Thus, Dalit students are more dependent on their faculty for educational guidance and support than their peers.”

The class, caste, religion, and gender intersect and play an important role in this process and also have a bearing on academic performance through the long period that they have to spend in the completion of the course. Therefore, interpreting the culture of the institution is critical for day-to-day negotiation. We often think that institutions are fair and just in terms of their values and culture. However, institutions reflect the larger society and its inequalities and biases. Given the elitist nature of medical education, the organizational culture of these colleges tends to embody the ideology of the upper middle class and caste. The two important driving agendas are majoritarianism and meritocracy, so questions around social realities do not get addressed in these institutions formally or informally. Any questioning of the status quo or resistance from those who are marginalized is often either ignored or repressed. I realized this aspect when I used to teach caste and gender dynamics in Indian society to doctors who came to do a Master's in Public Health in Jawaharlal Nehru University. I used the lived experience of caste and discrimination as a minority or a woman as a pedagogical tool to teach social science concepts. Through the years of teaching, I learned from my students how medical colleges are deeply casteist with little social relationships between the reserved categories and others. This was described as the norm and many of the students did not even think that this was unfair. I had a similar experience when I was asked to be a resource person to sensitize faculty at AIIMS following the recommendations of the Thorat Committee report.[3] Faculty were often defensive and kept asserting that they did not know the caste background of their students and only called them by their enrollment numbers. However, through the sessions, I was able to elicit their deep-seated prejudices in terms of merit and ability. While caste may be hidden, class prejudices are palpable in the interaction between faculty and students. Here, schooling and command over English define the social interaction in the medical college.

During the last few years, several incidents of suicide of medical students, belonging to the reserved category, visibilized the oppression and humiliation that they had to face with their peers and teachers.

 Caste is Alive and Institutionalized in Medical Colleges



In the wake of suicides of Dalit students in medical colleges, the media wrote on the subject quite extensively. An evocative headline “Casteism hidden behind White Coats” said it all. The keyword here is hidden because, in most middle and upper middle-class discourse, caste is not important or actively practiced. However, the key area of marriage is where one sees both caste and religion are extremely important. Equally important to recognize is that higher education meritocracy is closely intertwined with where a person is located in the caste hierarchy.

”Casteism in the medical fraternity is as deep-rooted as in any other part of society, says Brajesh Lahri, an MD, Ophthalmology student at AIIMS, Delhi.” It is just that it is not apparent and is hidden behind white coats. The first sentence I heard from a senior professor after joining was, “You people are lucky; you don't even need to study.” That statement ignored the fact that I had qualified in the general category. I could have got a seat in radiodiagnosis, which is considered the topmost branch, but I chose the branch that I loved. Such a comment was not what I was expecting at AIIMS, “he said.”[4]

An interview with a Dalit student in a medical college gives insight into the lived experiences of discrimination and humiliation that robs one of wellness.

”Upper caste students couldn't believe a Dalit could top”

”Adham jati mein shiksha paye, bhayahu yatha ahi dudh pilaye” (educating a lower caste person is the same as feeding milk to a snake) – “this was a saying I used to hear several times a day from a senior professor,” recalls Dr. Surya Bali, who belongs to a Scheduled Tribe and is currently working as an additional professor at AIIMS, Bhopal. He also holds a degree in Master of Health Administration from the University of Florida.[4]

Bali recalls, “From SGS Inter-College in Jaunpur, Uttar Pradesh, to AIIMS Bhopal, there have been hundreds of incidents wherein fellow students and even teachers tormented me over my caste. In 1989, I topped in my Thakur-dominated college. In response, upper caste students tore up my marksheet, as they could not believe that a Dalit student could stand first. They used to pass casteist remarks and mock me, asking why I was bothering to study, as ultimately I would have to work in the fields with my parents.” After his matriculation, Bali was discouraged by some from opting for the science stream. “Three teachers at the inter-college were against my decision to take science. Had another teacher not stepped in to help me, I wouldn't have been able to become a doctor. He told the other teachers that as I was the topper and wanted to study science, they should allow me to do so. Similarly, another upper caste teacher at the Banaras Hindu University helped me a lot during my tough college days.”

Bali clearly remembers the 5 years that he spent pursuing his MBBS at Moti Lal Nehru Medical College. He recalls, “Every day was like hell. The upper caste students used to ignore me, and when I befriended lower caste students, they would accuse me of being casteist. I survived 5 years in total isolation. There was also a lot of frustration inside me because I never availed reservation and was a topper throughout; yet people used to comment on my caste and color, and I was at a loss about how to convince them to give me a chance.” He further says, “In my 3rd year of MBBS during the final exam, a senior professor was conducting a viva examination along with an external examiner. I answered all the questions, while several others failed to answer them. All of a sudden, the professor abused three upper caste students, saying, 'You should be ashamed that a Dalit student is answering questions, and you, despite being upper caste, are not doing so.' I was left speechless initially, but later, I spoke up against his casteist remark.”[4]

 Intersectionality of Social Determinants



The demanding curriculum in medical colleges is known to produce a great deal of stress among students in general. Studies assessing the levels of anxiety and depression among medical students have observed that they were consistently high. It was higher among female students than male.[5] However, there are very few studies that have looked at wellness among students from reserved categories and religious minorities. The suicide of 19-year-old, Dr. Tadvi, in Mumbai illustrates how class, caste, and gender interact to perpetuate institutional discrimination.[6]

The problem of casteism, however, extends far beyond the walls of her hospital. Vijay Tadvi, a 19-year-old medical student who hails from the same Muslim Bhil community as Dr. Payal Tadvi, says similar slurs are thrown at him by seniors at his college in Mumbai on a fairly regular basis. “They say that I lack talent and I don't deserve my seat. They claim that I'm a barbarian who does not know anything because I come from a tribal area,” he says. Vijay Tadvi claims that getting a medical seat was especially difficult for him, given that his parents are illiterate farmers. “Getting low marks doesn't mean you are not talented. A student may study hard, but how is he to get anywhere without the means to enrol in coaching classes like open category students do? This perception is wrong,” he says. It's a story that finds resonance among tribal and backward caste students in most medical colleges. “I think cases of caste discrimination are ignored at the initial levels because faculty members mostly hail from the upper caste,” says another student. “It takes away the Student's confidence, preventing him from studying further.” His colleague, who belongs to a backward caste, claims that there are times when teachers award low marks to students just by looking at their surnames. “Discrimination is practiced even when seats are being allotted in medical colleges,” he says. “My friends wonder why I put in so much effort when I belong to the scheduled caste category. But that's not the case. The difference between the open and scheduled caste categories is hardly 5%. Dr. Payal Tadvi committed suicide by hanging herself on May 22. Justice CL Thool of the Maharashtra Scheduled Caste/Scheduled Tribe Commission told NDTV that many such students suffer in silence because they are too scared to disclose their identities. While some of these students come forward in all boldness to get relief, others are scared that the departmental heads will favour those from the upper caste, he says. According to the 2007 Thorat Committee report on Delhi's All India Institute of Medical Sciences, around 69% of students claimed that they did not receive adequate support from teachers, while 72% alleged caste-based discrimination in the classroom. Another 76% said that their papers were not checked properly, and 84% alleged facing discrimination during practical examinations.[7]

 Conclusions



One could say that the experience of wellness among medical students is a complicated terrain. One would argue that the multiple axes of inequalities – class, caste, religion, and gender identities – determine the wellness of medical students. While class and caste intersections have received some attention, other important axes of inequalities like religion and gender have not. We have anecdotal evidence of discrimination faced by religious minorities, especially Muslims and women from lower castes who bear a double burden in institutions of higher learning. These are aspects that need to be recognized and given visibility through research to challenge how institutions think and behave.

Medical colleges tend to be blind to these social complexities as a result there are few interventions at the institutional level to address the psychological problems that arise. As Maurya points out there are many factors that contribute to the socialization process in an institution of higher learning. These include caste affiliation, economic condition, financial and academic achievement. Apart from caste, gender, religion, and class are also important in forging relationships with peers and negotiating the expectations of those from more privileged backgrounds. Maurya presents the case of a research student regarding how class and caste interact in the socialization process.

”If the economic condition of your family is good, then caste identities do not matter much because you will be able to spend money in your group. Most of the students of Dalit community belong to a very poor family background. Therefore, they are unable to mingle in a group of UC (upper caste) students who generally belong to families having good economic resources. Most (Dalit) students spend time with students of their own caste.”[2]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Mishra P, Singh B. Clash of competitions: A Study of coaching classes of Kota. Eur Acad Res 2017;5:2888-909.
2Maurya RK. In their own voices: Experiences of Dalit students in higher education institutions. Int J Multicultural Educ 2018;20:17-38.
3Thorat Committee Report (2008) Report of the Committee to Enquire into the Allegation of Differential Treatment of SC/ST Students in All India Institute of Medical Science, Delhi. Available from: https://www.scribd.com/document/55596479/Prof-Thorat-Committee-Report-on-AIIMS#fullscreen&from_embed. [Last accessed on 2021 Jun 11].
4'Casteism Hidden behind White Coats': Students, Professors say Medical Field Rife with Bias Against Marginalised. Available from: https://www.firstpost.com/india/casteism-hidden-behind-white-coats-students-professors-say-medical-field-rife-with-bias-against-marginalised-6755401.html. [Last accessed on 2021 Jun 11].
5Iqbal S, Gupta S, Venkatarao E. Stress, anxiety and depression among medical undergraduate students and their socio-demographic correlates. Indian J Med Res 2015;141:354-7.
6Payal Tadvi Suicide Case: The Death of a Doctor. Available from: https://www.livemint.com/mint-lounge/features/payal-tadvi-suicide-case-the-death-of-a-doctor-1559891147950.html. [Last accessed on 2021 Jun 11].
7No Cure for Casteism in Mumbai Medical Colleges Shaken By Doctor Suicide. Available from: https://www.ndtv.com/india-news/from-discrimination-to-slurs-how-casteism-lives-on-in medical-colleges-2047338. [Last accessed on 2021 Jun 11].