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Equity and AccessHealth Care Studies in India$

Purendra Prasad, Amar Jesani, and Sujata Patel

Print publication date: 2018

Print ISBN-13: 9780199482160

Published to Oxford Scholarship Online: July 2019

DOI: 10.1093/oso/9780199482160.001.0001

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Caste, Class, and Gender on the Margins of the State

Caste, Class, and Gender on the Margins of the State

An Ethnographic Study among Community Health Workers

(p.245) 11 Caste, Class, and Gender on the Margins of the State
Equity and Access

Madhumita Biswal

Oxford University Press

Abstract and Keywords

Dichotomous view of state and local communities remains a dominant theme in the theorization of state. State often gets depicted to be mainly working on the basis of a rational principle as opposed to the irrationalities of the local communities. This chapter makes an attempt to understand how such claims about state takes an actual course while making available some of the basic needs like health services. It argues that gender and class bias remain inherent at the very structuring level of the health programmes. Further, the bureaucratic hierarchy of the state and the hierarchies of the local communities seem to converge on many occasions.

Keywords:   State, Local communities, caste, class, gender, embodiment

Ethnographic studies on the working of the state have gained considerable attention in the recent times (see for instance, Das and Poole 2004; Ferguson and Gupta 2002; Scott 1998; Sharma and Gupta 2006). One of the concerns of such ethnographic investigations is to critically engage with the interface between the bureaucratic apparatus of the state and local communities. This chapter attempts to focus on the activities at the points of intersection of the state and local community through an enquiry into the state-health interventions. Drawing on an ethnographic study1 carried out in Boudh district of Odisha, the chapter engages with the working of the state at two levels. In the first part it tries to map how the Indian state-health discourse intervenes in the lives of women from marginalized communities through the routinized practices of its bureaucratic machinery. The second part examines questions of the identity of the institutional agents of the state, and how the embodiment of their identity intersects with their modern professionalism in everyday negotiations.

Partha Chatterjee (1997: 279) has observed that the postcolonial Indian state conceives its bureaucracy to be a ‘universal class’, ‘working for the universal goals of the nation’, and thereby claiming to be working (p.246) on a single rational consciousness or will of the state. However, it may also be argued, as we do here, that the embodiment of the caste and gender identities of the institutional agents of the state seem to be playing an active role in giving expression to the practices of the state.

In the popular imageries of state, a dominant image is that of the state as an ‘external and distant entity’, which may be seen ‘either as an oppressive intruder of the affairs of the local community or as a benevolent protector of people against local oppressors’ that is determined contextually (Chatterjee 1997: 295–6). This imagery of state as up above the local communities is well articulated by Ferguson and Gupta (2002). They point out that notion of the supremacy of the state over local communities often tends to depict the state and local communities through spatial and scalar hierarchies, finding expression through verticality and encompassment. According to Ferguson and Gupta:

Verticality refers to the central and pervasive idea of the state as an institution somehow ‘above’ civil society, community and family. Thus the state planning is inherently ‘top down’ and state actions are efforts to manipulate and plan ‘from above’, while ‘the grassroots’ contrasts with the state precisely in that it is ‘below’, closer to the ground, more authentic, and more ‘rooted’. (2002: 982)

Being ‘above’ the local community, the main concern of the state is planning for the benevolence of local community and intervening in a top-down manner through its routinized functions of bureaucracy. In contrast to the state, local communities are perceived as ‘on ground’ (Ferguson and Gupta 2002: 982). Similarly, through the idea of encompassment the state is viewed as superior to, and encompassing the diverse institutions of power situated at the local level. However, the vertical imagery of the state has come under critical scrutiny. Community participation and democratic decentralization have been propagated as tools to counter such a top-down approach of the state.

The interesting paradox in India is that while, the state in principle ostensibly supports the notion and ideology of community participation, it is simultaneously ensuring its bureaucratic presence in village communities through the garb of community participation. In reality the vertical imagery of the state remains intact. For instance, in appointing community-level health workers, such as anganwadi workers (AWW) and accredited social health activists (ASHA), while the village community approval is sought in the guise of ensuring community participation. Once selected, the community-level health (p.247) workers are easily inserted into the bureaucratic structures of the state. So these community-level health workers by virtue of occupying the space between the state and community are often perceived in terms of their dual roles: as agents of the state, located at the margins of the bureaucratic structure, and as representatives of the local community. This is true of both AWWs and ASHA workers.

These intersecting zones between community and state are of immense significance in the context of implementing state-health interventions because the community-level workers become the key agents in carrying forward the state agenda at the local level. In other words, these community-level health workers serve as village-level bureaucrats in carrying forward state agenda. In a way the villagers experience the state through these village-level bureaucrats routinely, everyday. In fact, the community-level health worker functioning in village space as an ‘agent’ of the state certainly challenges the dominant notion that the state is an ‘external and distant entity’. The following section discusses how the assertion of the state power at the village level is made through the everyday mundane work of its village-level bureaucracies.

Gender, Class, and Reproductive Surveillance

It has been well acknowledged in feminist scholarship on health that women’s reproduction has gained specific attention in the post-colonial development discourse (Chatterjee and Riley 2001; Hollen 2003; Kumar 2006; Ram 1998). Myriad relationships among different sectors such as poverty, education, and health have come to be linked to women’s reproductive behaviour. With the nation being drawn to the global ranking system of development, women’s reproductive behaviour has come to be linked to indicators of development. Improper management of women’s reproduction is conceived to be having the potential of creating an obstacle in India’s narrative of development in the world stage. Generating knowledge about women’s reproductive behaviour, extensive planning, and surveillance remains a key in designing development interventions. This rationale takes an elaborate form in the everyday pedagogical functions of the state.

In the everyday practices, the increasing intervention of professionals has become a reality (also see Anagnost 1995; Escobar 2010). However, scholars like Ram (2001) and Hollen (2003) also point out that in this discourse not all women are drawn to the statist developmental discourse on an equal footing. Women from marginalized categories such as rural (p.248) women, urban slum women, tribal women, dalit women, and women from Muslim community are constructed as the problem categories, responsible for the backwardness of the country. Hence, most of the interventions are directed towards these women. Further, scholars like Mohan Rao (2004) observe that the dominance of selective primary health care (SPHC) approach in the Indian development discourse makes it impossible to acknowledge the structural issues involved in generating the health problems. Rather, health problems have come to be individualized and considered as problems which could be sorted out through the technical interventions of the health functionaries.

Based on a field study conducted among the community-level health workers in the Baunsuni Block of Boudh district of Odisha, we attempt here to map how rural women are drawn into the development discourse through the mundane routinized activity of the bureaucratic machinery. In the rural areas a series of developmental institutional agents like AWWs, ASHAs, Auxiliary Nurse Midwives, and Lady Health Visitors, whatever their stated roles, are charged with reforming women’s reproductive behaviour in different ways. Village-level health workers, such as, the AWW and ASHA, for instance, are often projected as the symbols of community participation. In 1975, the Government of India had launched the Integrated Child Development Services (ICDS) programme, through which initiatives were made to appoint AWWs in villages. A woman from among the village community was appointed as AWW. Her responsibility was to look after the health and nutritional needs of mothers and children. The Integrated Child Development Services project was launched in the Boudh District of Odisha in 1993. Further, in 2005, another rung of community-level workers, ASHAs were introduced through National Rural Health Mission. Like the Anganwadi worker, the ASHA is also necessarily a woman functionary, selected from the village community that she is required to serve.

Most of the community-level health workers are women. The gendered nature of the state in drawing women from the economically weaker sections to underpaid, low remuneration community welfare work has been highlighted in feminist scholarship (Dressel 1987; Kabeer 1994). However, the introduction of different layers of women bureaucratic agents is of immense significance. On the one hand, in employing primarily women as community-level workers, the state in a way proactively acknowledges women’s health needs, and more particularly, women’s reproductive health needs as its main concern. (p.249) On the other hand, since the community-level health workers (mainly AWWS and ASHAs) are members of the village community, the state is ever present in the village through these bureaucratic agents.

Such insertion of the bureaucratic agents in the village space keeps women in a double bind. Community-level workers are key agents in making available the state health services, in situations of desperate need. From another angle, now women, are not only under biomedical scrutiny when they visit hospitals, but by virtue of the state health agents being located within the village space, ordinary women can no longer easily escape the statist gaze (also see Ram 1998: 114–43). Working close to village women, as they do, these community-level workers can exercise close scrutiny over women’s behaviour. This is well reflected in the views of some of the AWWs. According to one of the Anganwadi workers:

In the village we establish good rapport with most of the Self Help Group (SHG) women, who inform us about the new pregnancy cases in the village. We also get to know about the pregnancy cases through our daily home visits, from neighbors and while talking to women in the village. After getting confirmation about a pregnancy case, we keep track of the person. After completion of three months of pregnancy we dispense the first TT to the expectant mother and provide iron-folic acid tablets, which she is asked to consume regularly. The woman is also given chloroquine tablets and told about the procedures of consumption. The pregnant woman is asked to attend health camp every month, and is also provided with supplementary food by the Anganwadi centre from the month she takes her first TT. In the fifth month of pregnancy another TT injection is given. In every health camp we enquire whether the woman is taking the iron-folic acid tablets and chloroquine tablets properly or not. Through our daily visits also we ensure that the woman takes medicines properly. When women do not agree to take TT and other medicines during pregnancy we persuade them, and if they do not agree the ANM of the locality and the PHC doctor try to persuade them. From seventh month onwards we ask the pregnant woman to take proper food and also ask them to remain prepared for the delivery. They are supposed to inform ASHA as soon as the delivery pain comes and go to the health centre for child birth.

(Extracts from fieldwork)

The above narrative foregrounds the complexities involved in such a close scrutiny of women’s behaviour. For instance, what happens when women refuse to conform to the prescribed medical practices that (p.250) operationalize the medicalized reformatory agenda of the state (as for instance, if a woman were to refuse to take TT or chloroquine or refuses regular medical checkups or to go for hospital delivery)? The moment women refuse to conform to the medicalized discourse propagated through the village-level bureaucrats, they come to be labelled as irresponsible, superstitious, stubborn, backward women, responsible for risking the life of their children as well as themselves. Responsible behaviour gets defined as that which is in agreement with the highly medicalized discourse. Their nonconformity to the statist agenda makes them subjected to persuasion by various state functionaries. This vocabulary of persuasion in actual practice turns out to be a pressure building mechanism.

Through a series of bio-medically rationalized interventions such as hospitalization of childbirth, medicalization of pregnancy and child-rearing practices, execution of sterilization and sanitation programmes, women become the key objects of statist reformist agenda. This idea of reformed, responsible woman is very much structured by their caste and class location. Many illustrations maybe cited of the way in which the lower-caste and lower-class women confront the class-based challenges in their everyday life in meeting this normative standard of responsible motherhood. We elaborate two examples.

Over the last few decades there has been a renewed focus on breastfeeding that has been operationalized at the community level by the state’s functionaries. In the villages the main agenda is to prompt women to adopt breastfeeding, promoting it as being a scientifically approved method. Many breastfeeding campaigns have taken place at the PHC sub-centre level over the last few years in the Baunsuni PHC area. Health functionaries counsel women to exclusively breastfeed new born children for at least six months. Not surprisingly it is the lower class labouring women who bear the brunt of such campaigns. An older generation of lower-class women are now being glorified for having ‘traditionally’ breastfed their children, while new mothers are perceived as challengers who may upset such ‘traditional’ practices through their ‘irresponsibility’ (Hollen 2003). In recasting an old and traditional practice as a scientific/medical practice in whatever the situation, the health workers/agents of the state acquire the moral authority to judge rural women from a lower-class. This is reflected in the narrations of an Anganwadi worker:

In this locality, many women do not take care of their children properly. After two-three months of their delivery, they join the work in the field by leaving the child under the supervision of some family members. (p.251) Mothers need to pay full attention to their children during their infancy. The agricultural ripping period is going to start from next month. From now onwards the mothers will be busy in the agricultural work for coming five to six months. Under my Anganwadi center now all the children are in the ‘normal’ category. But I know in the coming two months the children’s health standard is going to fall. Since most of the mothers will be busy in the agricultural work, they will not take proper care of their children. Therefore, during agricultural season we need to pressurize mothers and remind them more often to take proper care of their children.

(Extracts from fieldwork)

It is evident that this is one of the pathways by which the health worker gets to shift the responsibility of the well-being of the child entirely on the woman rather than the state’s health system and social conditions. This also relieves the entire family/community from the responsibilities of child care. A biological function, that of breastfeeding, becomes the linchpin for the statist reordering of social relationships.

There has been constant advocacy by the state to promote hospitalization for childbirth. Different schemes are initiated to lure poor women to use hospital for childbirth. In 2005, the Janani Surakshya Yojana was launched through National Rural Health Mission. This scheme was to bring modifications in the maternity benefit scheme. It further intended to integrate antenatal care during pregnancy, institutional care during delivery, and immediate post-partum period. Through this scheme institutional delivery was promoted, by providing financial assistance to women who go through hospital delivery. While the programme promised cash benefits to women up to two live births, the monetary assistance for the third childbirth was assured to women only if they accepted sterilization after the third delivery. Further, for undergoing family planning operation after delivery, women were assured additional cash incentive (Government of India 2005).

As is evident, hospitalization for childbirth is very closely tied to family planning programme in general and female sterilization, in particular. One of the major duties of ASHAs in the villages is to motivate the pregnant women for hospital delivery and accompany them to hospital for delivery. And since most of these women are from the poorer classes, it is they who are the main targets of the statist propaganda of female sterilization. So the scheme indirectly pressurizes them to seek sterilization. The statist agenda of hospitalization for childbirth may be seen as a ploy to regulate and discipline the reproduction of women from lower economic background. (p.252)

The vertical/hierarchical imagery of the state gets well defined through the mundane routinized practices of community-level health functionaries. They become the key institutional agents through whom the verticality of the state gets well depicted. For example, one of the main responsibilities of the Anganwadi worker is to maintain records of the weights of children in her Anganwadi area. As part of the job, she is expected to persuade mothers to be very attentive towards maintaining a certain weight level of the children. The Anaganwadi worker while on the one hand exercises surveillance over women’s child-rearing practices, on the other hand her own managerial skills are closely scrutinized by her higher authorities, her supervisors. The Anganwadi workers, being in the lowest rung of the hierarchy in the state machinery also remains a vulnerable worker, who is prone to be blamed as being irresponsible and/or inefficient. Her efficiency is determined by her ability to pressurize the mothers to ensure their children do not fall out of the ‘normal’ contour, the normal standards. This fact that she performs her job efficiently lends weight to her moral authority to intervene in the reproductive health behaviour of women.

Community Health Workers’ Everyday Negotiations with Gender, Caste, and Profession

In discussion so far the institutional agents of the state mainly appear to be guided by the statist ideology of class inequality. As agents of the state, they are ideally expected to take up the ‘universal roles’ and their embodied caste, class, ethnic, and religious identity, is expected not to interfere with their professional responsibility. However, the fieldwork among the community-level health workers in Baunsuni reveals that the caste identities of women play a crucial role in not only determining who can be a suitable community health worker, but also how the community health worker is going to deliver her service.

Scholars like Debabar Banerji (1982) and Mark Nichter (1986) have pointed to the way the democratic process is subjugated by the village power structure to serve the interests of the privileged communities. Such a trend is also well reflected in my field site. The caste of the women remains a major influencing factor in the appointment of the community-level workers such as AWWs and ASHAs. They are seen as symbols of community participation. Hence, the involvement of the village community is sought during their recruitment. The Baunsuni (p.253) sector of ICDS programme has 21 Anganwadi centres and every centre has one Anganwadi worker. Of these 21 Anganwadi workers five are from Brahmin castes, 13 are from Other Backward caste groups,2 more particularly belonging to Dumbal, Hatua, Teli, Sudo, Bhulia Meher, and Bania castes, and one is from Keuta3 caste, a group that is a recent entrant to the Scheduled Caste category. Two of the AWWs are from Scheduled Caste categories, considered to be untouchables4 (who self-identify themselves as ‘harijans’). So although the Brahmins are a minority community in Boudh district, they form a sizeable number of AWWs. Further, the discussions surrounding the appointment of ASHA in the village showed that castes of the women become a major decisive factor in their appointment.

Recent studies on community-level workers especially ASHAs have mainly drawn attention to the functioning of the ASHA in the local village community (see Roalkvam 2014), the mutual trust of relationship between ASHA and villagers (Mishra 2014), performance of ASHAs (Bajpai and Dholakia 2011). Though a study by Farah N. Fathima et al. (2015) in Karnataka has focused on the selection processes of the ASHAs, they have mainly drawn attention to the participants’ class backgrounds.

As stated earlier, the involvement of the institutions of the village community, such as, gram sabha, the village panchayat, and the village heath and sanitation committee is required in the selection of ASHA (Government of India 2005). ANMs and male multipurpose health workers also play observer roles in the selection process of ASHA, while the AWWs of the village along with the village committee members play an important role. The responses of the AWWs, ANMs, and Multipurpose Health Workers (MPHWs) of the Baunsuni PHC, make it clear that women from the untouchable Dalit communities are least likely to be appointed as ASHA. They point out that on most occasions the members of the gram sabha and the panchayat do not want to appoint an ASHA belonging to untouchable Dalit group. According to one of the ANMs in the Baunsuni PHC:

No harijan woman is selected in our sub-centre area as ASHA. In one of the villages, one woman belonging to the harijan caste community had applied for the post. Though I was interested to select her, the village committee did not want to select a harijan woman as ASHA. Hence, I could not do anything. In most cases the Anganwadiworker does not want to select an ASHA from harijan caste communities, because she has to work with her on a day-to-day basis. Again the village committee (p.254) and the panchayat have to get involved in the selection of ASHA, and they do not want to appoint a woman belonging to the harijan caste group. They want to accommodate a woman who belongs to their touchable caste. Hence, the selection of a harijan woman as ASHA becomes difficult.

(Extracts from fieldwork)

While most of the time though the ANMs, AWWs, and MPHWs in their own way contribute in producing such a hegemonic discourse, the responsibility for such decisions is often shifted to the other members. However, some of the ANMs and MPHWs belonging to the untouchable Dalit community pointed to the fact that as a survival strategy, they often consciously take a decision of not supporting the candidature of applicants belonging to their community. One of the MPHWs of Baunsuni PHC said:

Nine ASHAs have been selected in our sub-centre area. Though one ASHA is from scheduled caste, she is from touchable keuta caste. Because of the caste feeling, women belonging to untouchable communities do not get appointed as ASHA. Though I belong to a harijan caste, I have not selected a single ASHA who belongs to my caste. Even though sometimes women belonging to my community apply for the post, I am compelled to support the candidature of an upper caste woman rather than the woman belonging to my caste. To survive in the locality I need to be in good terms with the panchayat and the village leaders. If I support the candidature of a woman belonging to my community as ASHA, the village community is going to stand against me. Hence to avoid such situation, most of the time I advise the interested candidates from my caste community not to apply for the post.

(Extracts from fieldwork)

In most village communities women belonging to the untouchable Dalit groups are, clearly, the least preferred candidates for the ASHA post. It is easy to see that what gets recognized as the ‘village community’ is, in fact, the dominant section of the village. Hence, their hegemonic public opinion gets construed as the ‘public opinion’ of the village. Though the state’s guidelines for the formation of village health committee emphasizes the involvement of members belonging to the Scheduled Caste, the ‘touchable’ caste like Keuta caste is most often preferred and co-opted as the representative of the Scheduled caste community rather than a person belonging to the untouchable Dalit groups.

The testimony of one of the respondents draws attention to the fact that on one of the occasions only one untouchable Dalit woman had (p.255) applied for the post and while the village committee had to give its approval for her appointment, the ANM of the locality openly expressed her displeasure over her appointment. According to her, women from the touchable caste groups would have access to the households of the upper caste groups, while a lower caste woman would not be entertained by the upper caste households. In such articulation the interest of the upper caste groups comes to be equated with the interest of the village community as a whole.

On a few occasions, the ANMs and MPHWs perceived that the lower caste women are the most suitable candidates for the ASHA post because, the ASHAs have to deal with women during their childbirth period, which is considered to be polluting. It was argued, as an ASHA is required to escort and accompany women to the health centre during their pregnancy and engage with neonatal care (considered to be a polluting state), women from lower caste groups would be more suitable. As an ANM pointed out:

In our sub-centre area two ASHAs are from ‘untouchable’ ganda community. People were initially opposing the appointment of these women as ASHAs. Though some upper caste women had applied for the post, none of them were meeting the eligibility criteria. The women belonging to the lower caste communities were meeting the eligibility criteria. Hence I convinced the villagers saying, if an ‘untouchable’ woman becomes an ASHA, she need not touch you always and go to your home. She is mostly required to help women during their pregnancy and after pregnancy. Anyway, women stay in a pollution state till the fifth day of their pregnancy. Hence, the physical contact of an untouchable ASHA is not going to be a problem during the pollution state of women. And after fifth day, anyway women are going to purify themselves. Since ASHA is going to help women during pollution state, lower caste women are good for such job.

(Extracts from fieldwork, emphasis present in original)

To interpret the above, upper caste women are often invited into the statist discourse in taking up the public role of being the agents of development with an unmarked universalized identity. However, the lower caste women enter into such a discourse of development only as governed bodies and objects of surveillance. Here, it is interesting to note that when lower caste women’s inclusion in the public role is sought, their caste marked stigmatized bodily identity itself becomes the idiom through which their entry gets legitimized (see Pinto 2006). (p.256)

Even though upper caste women enjoy the advantageous position of taking up public role in getting appointed as community-level health workers, they cannot afford to emphatically shun social contacts with the lower caste communities. They are required to exercise a ‘statist gaze’ over the lower caste community women, as a part of their bureaucratic function. However, this does not mean the disappearance of the practice of caste from the lives of these modern professionals. In the pursuit of professionalism, new boundaries seem to have been drawn. Many frontline health workers in the field articulate this duality of roles. According to an AWW:

Children from all caste groups come to study in the Anganwadi. We do not practice any kind of caste discrimination. But while serving food to children in the Anganwadi centre, the upper caste children are served food in the Anganwadi and the children from harijan caste groups are sent home with the food. They are not served food in the Anganwadi. This system has been practiced because the upper caste groups do not want their children to sit beside a child belonging to the harijan caste group, while having their food. I need to conform to some of the minimum caste norms as a woman from upper caste group.

(Extracts from fieldwork)

Further she says:

In this village I have survived as an Anganwadi worker because I have tried to strike a balance between the upper caste groups and the harijans. I do not neglect harijans while providing service. While delivering the service I have to keep in mind the interests of both the upper caste groups and the harijans. For instance, while measuring the weight of children, I cannot skip measuring the weight of harijan children. If I come to the upper caste pada after measuring the weight of harijan children, the upper caste people will not allow me to measure the weight of their children. Hence I try to solve the problem by measuring the weight of upper caste children in the morning and going to the harijanpada in the afternoon to measure the weight of their children, on the health check up days. Being a married woman from a Brahmin caste, I also need to conform to the customs of the family and caste. Hence each time I come in contact with the untouchable communities I take bath before entering into the inner space of house.

(Extracts from fieldwork)

One often encounters situations where the interests of state actors comfortably colludes with the dominant group interest, resulting in keeping the lower caste groups at the margins in accessing state services. (p.257) However, such a discriminatory attitude often seeks a refuge through the justification such as ‘facing pressure’ from ‘village community’. The community-level health workers often find an escape route by putting the blame on the ‘village community’, which seem to be less accountable. Further, the community-level health workers from the dominant communities often try to justify their own caste practices through suggesting dichotomies in their roles and practices in terms of public/private, state/familial responsibility. They often try to justify their attempts of maintaining bodily purity, by taking a bath each time they come in contact with the untouchable castes, as a private practice, which does not come into conflict with their public roles.

Gopal Guru (2009b: 55) suggests this kind of dichotomization of space into public/private and domestic/state provides an opportunity to ‘feel sovereign over controlling the domestic space’. Such sovereignty remains unattainable in continuous time and space. Hence, fragmentation of time and space gives the upper caste health functionaries an opportunity to escape from the universal identity and feel sovereign at the domestic space. This fragmentation of time and space allows them to perform two seemingly contradictory roles such as conforming to the dominant gender role of being the bearer of caste purity on the one hand, and taking on the universal role of health worker of the whole village community on the other hand. The attempt of conforming to the gender-based caste norm is expressed in several ways, such as taking care to maintain bodily purity by making minimal visits to untouchable Dalit pada and taking a bath after each visit. Fragmentation of time and space is also achieved through arranging separate time slots for untouchable Dalit women and upper caste women for health checkups and food distribution.

While the upper-caste community health workers can often afford to have the luxury of fragmenting their time and space in performing their professional responsibility, community-level health workers from the untouchable communities enter their public roles with a deep sense of reduction (also see Guru 2009a). The acceptance of servility by the community health workers belonging to untouchable communities, becomes one of the ways through which the cordial relation with the village community is sought. This exercise of self-restraint while performing her public role is evident with the discussion with an AWW belonging to untouchable caste:

Though the Anaganwadi worker is supposed to measure the weight of children, I cannot measure the weight of upper caste children because (p.258) of my caste status. The upper caste people will not like me to touch their children and measure their weight. I also need to maintain cordial relation with all the caste groups. Hence I abide by all the caste rules and do not try to transgress it. The Anganwadi helper, who is from gaud caste (a middle level caste), measures the weight of upper caste children and I only stand at a distance and monitor it and note down the weight of children. Also during cooking food and serving food in the Anganwadi, I keep a distance from the site.

(Extracts from fieldwork)

So far the discussion has focused on how the community health workers’ complicity is established with the hegemonic caste interest in the village community. This in turn gives us the impression that these hegemonic tendencies go uncontested. However, voices from the field often reinstate the fact that assertion against such domination is often made, though not in an organized form. Further, in such cases of fragmented assertions one may witness that different power structures, from state machineries to non-state actors, try to come together to suppress such assertion.

An incident involving the shifting of an Anganwadi centre from a space located at the interface of the ‘untouchable’ Dalit pada and upper caste pada to a ‘proper’ upper caste pada of the village demonstrates the way the assertions by the untouchable caste groups are suppressed. In that village in the Baunsuni Block, initially the Anganwadi centre was established at a space very closer to untouchable pada, at one end of the upper caste pada. As the general practice in almost all the Anganwadi centres in Baunsuni, here too cooked food was being served only to upper caste children with the untouchable children being sent home with their share (since neither the AWW nor the helper, both upper caste women, wanted to clean up after these children had eaten).

At some point, a member of the untouchable caste group came inside the Anganwadi and demanded that either the children belonging to untouchable castes should also be served food inside the Centre, or no child should be served food inside. This incident was, later deliberately misconstrued as the unreasonable demands of drunken man, projecting it to be an attack on the modesty of the AWW and her helper. Hence, a demand for social justice, that is, assertion of the right of the children from untouchable communities to consume food within Anganwadi centre, got construed as an act outraging the modesty of upper caste women. The village committee, Anganwadi supervisor, as well as (p.259) Community Development Project Officer of ICDS (CDPO) held meetings and decided to shift the Anganwadi centre to the upper caste pada. To be sure, the shifting of the Anganwadi in a way was seen as a response to a larger change in the village landscape, where untouchable Dalits were seen to be overstepping the limits of their caste status, which is defined by submissiveness (also see Kannabiran and Kannabiran 2003: 249–59). In such a situation, it was seen to be dangerous for the upper caste women to perform their public role in the space. This incident draws our attention to the complex ways in which gender and caste intersect.

The chapter began with analysing the dominant imaginary of the state as a supreme agent over the local communities, as discussed in the scholarship. It is also argued that the state justifies its position based on the claim that it works on a rational principle vis-à-vis the supposedly irrationality of the local communities. Planning and intervening in the lives of local communities through its bureaucratic apparatus, for the benevolence of the local communities is projected to be the main concern of the state. However, the study with community-level health workers in the Boudh district of Odisha shows that though the state tries to project itself to be working on a principle of universal rationality, class, caste, and gender bias remain an underneath theme. Women from marginalized categories become the main target of the statist health interventions, who are in many ways pressurized to conform to the biomedical agenda of the state. Further, in analysing the everyday routinized practices of the CHWs in delivering their services across caste groups also challenges the dichotomized understanding of state and local communities. The bureaucratic hierarchy of the state and the hierarchies of the local communities seem to converge on many occasions. What could be derived from the working of the state agents at the local level is that through dispersed communitarian networks the state power is coordinated and consolidated. Hence, the caste and gender hegemonies at the local level could be seen to be playing a crucial role in the statist process of governance. In contrast to Ferguson and Gupta’s proposition that hierarchized model of state and local communities gets challenged in contemporary times with new forms of transnational governmentality, the chapter argues that even outside the transnational networks, the way the interaction between state and local communities gets played out on (p.260) a day-to-day basis, such neatly hierarchized model of state vis-à-vis local communities also gets challenged.

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(1.) This chapter draws on an ethnographic study conducted during 2006–07 among the community level health workers in the Baunsuni Block of Boudh District of Odisha. The broader term community level health workers, is used in the study to refer to the grassroot level health workers such as Anganwadi workers (AWWs), Auxiliary Nurse Midwives (ANMs) and Multi-Purpose Health Workers (MPHWs). Though AWWs, ANMs, MPHWs broadly carry out the health services, they belong to different institutional setups. While the ANMs and MPHWs are a part of the state health sector, the Aangnwadi Worker functions as a part of the Integrated Child Development Services (ICDS) programme. In-depth interviews were carried out with all the 21 AWWs of the Baunsuni sector of the Boudh Sadar Block ICDS programme. In addition to this, responses were also collected from 16 ANMs and 12 MPHWs. The years 2006 and 2007 mark a significant period in terms of the study with the community level health workers, because in the year 2005 NRHM was launched, which introduced a new rank of community level health worker ASHA. During 2006 and 2007 the procedures of appointment ASHAs was getting carried out in the Baunsuni PHC area. This particular time becomes significant because enthusiastic discussions about the suitability of diverse categories of women for the post of ASHA was carried out among both community level health functionaries as well as different sections of population within the village community.

(2.) Boudh district is considered as one of the Backward caste zones, having high concentration of population belonging to backward caste groups. As per 2001 census, the scheduled caste population of the district is as high as 21.90 per cent in comparison to the state average of 16.20 per cent.

(3.) The Keuta caste community is formally included in the scheduled caste category in Orissa in the year 2002. Since, the community belongs to a touchable caste group, on most occasions the village community members find it most convenient to include Keuta caste group member for fulfilling the requirement of scheduled caste representative, rather than including a person who belongs to untouchable caste group.

(4.) In the context of inclusion of Keuta and Dhibara caste groups in the Scheduled Caste category, the ex-untouchable communities have started organizing protest against such inclusion. The organized protest has started reclaiming the untouchable identity, by forming an organization named ‘Asprusya Dalit Sarankhyana Surakshya Samiti’. Hence, hereafter I would be using the term ‘untouchable Dalits’ to refer to the Dalit caste groups who have been historically subjected to untouchability.