Selective Scarcity: A Queer Lens at India’s Health Care Imbalance
Photo: Foundry Co from Pixabay
Survival in the pandemic continues to favour the powerful and privileged, while those in the margins face a scarcity and failure of the health care system. Aryan Somaiya and Sadaf Vidha confront this imbalance from a queer lens.
- Aryan Somaiya and Sadaf Vidha
Imagine braving the fear of the first wave of coronavirus, when so many of us were scared to step out, had little information about the virus’s true severity, and stared at the long uncertainty ahead of how long it would be for life to open up again. Imagine wearing masks, gloves, spraying sanitizer everywhere, and showing up to your doctor’s clinic for an important treatment. Imagine then, being told, that your need is not “essential”.
That is exactly what the co-author of this essay was told when he went to get his testosterone injection. As a transman, Aryan needs his testosterone shots in order to appear more like the gender he sees himself as. With a quick flick, something vital that may reverse these gender-affirming signs was disregarded
Picking and choosing what has been considered ‘essential’ care has come down to a larger question of ‘scarcity’. Inequalities in health systems are often blamed on scarcity. In the global context, and especially in India, this scarcity refers to the lack of resources, personnel, medications and funding that often plague the system. The scarcity is often the reason provided when the health care systems fail to cater better to people on the margins of power: women and other non-male genders, caste and class minorities, LGBTQ populations, tribal, adivasi populations, and the poor.
This answer is too simplistic, and does not fully address to the causes of scarcity, or the privileged few who do benefit in a time of scarcity. Shrecker (2012) in their paper on interrogating scarcity, pointed out the following important elements:
1) Capital flight: This refers to the idea that, though everyone works to produce capital, the CEOs and industrialists take the capital outside of the country of production as their own wealth in offshore accounts. The result of this is that the worker breaking his back to produce capital sees no benefits of this capital being used to improve health care systems in his own country.
The scarcity is intentional in order to keep the marginalised at the margins… We need a new queer bio-ethics, but those which make use of existing systems, not create new ones.
2) Social determinants of health and illness: One of the driving factors of ill health is poverty which is socially and structurally created. Another one is stigma, which again is the result of social factors. That both these determinants are caused by imbalance of power by the rich, never make it to discussions on health care and infrastructural inequality.
3) The absurdity of the question of return of investments in health expenditure: This is the idea that just like a company would measure return of investments before starting an employee training program, even spending on health care should have “returns” that help capitalist systems. That health care is a basic right that everyone should get, is in itself not enough in a capitalist world.
The 2020 coronavirus pandemic has indeed highlighted the points that Shrecker made. It has been clearly established that survival in the pandemic—right from getting yourself tested, to quarantine, to getting quick and helpful treatment—is much easier for the rich and privileged. As Kumar and Pal (2018) show, we have achieved the doctor patient ratio required by WHO. Therefore, the narrative of scarcity cannot be peddled anymore. As a paper by Meghan Romanelli and Kimberly D Hudson suggests, “The root causes of system-level barriers were all attributed to social-structural factors that worked to exclude and erase LGBT people from the institutions that shape the health and mental health systems.”
Often, these questions, comments, and criticisms are met with a line of response similar to “go to Pakistan if you have a problem with India”. That is, often the people asking questions are told to “make their own systems” if the current systems discriminate against them. And yes, marginalised communities have indeed taken this route, especially during the AIDS epidemic that plagued the gay community in America.
However, this response/way of coping has an inherently “othering” quality, quite akin to how those at the center of power push the powerless to the margins. “The vilification of LGBTQ members has in fact become a norm, with doctors, instead of treating the ailment, often sexually harass or abuse a transgender, or worse, condemn the “unnatural sexual preferences" of the person. There was even a case of a transgender, a victim of a train accident, dying unattended, because for 3-4 hours, doctors could not decide whether to admit her to a male or female ward.” This shows that it was not about the number of beds but about the intentional scarcity.
In his 2018 piece for Mint, Ashwaq Masoodi laid bare the huge gap between the accessibility and minority population due to discriminatory treatment received by LGBT population. A 2016 Lancet paper on transgender health in India and Pakistan says that while the transgender community may have received legal recognition, its access to quality healthcare remains alarmingly scarce. And, there are hardly any anti-discrimination laws in place to safeguard equality in health care access.
“A lot of trans people don’t even go to the hospitals for years, unless there is an emergency, say, an accident,” says Shuvojit Moulik, founder of Civilian Welfare Foundation, an NGO based in Kolkata. “They fear going to the hospital because of layers of homophobia that start from the guard to the receptionist to the doctors to lab technicians.”
As the lived experience of the author shows, trans needs are not considered essential. This shows that the scarcity is intentional in order to keep the marginalised at the margins. This means that within existing structures, service utilisation by LGBT population is low, and the discrimination they experience is quite high. We need a new queer bio-ethics, but those which make use of existing systems, not create new ones.
From the lens of queer theory both discrimination within the system and asking the marginalised to build their own system are forms of ‘othering’, which those at the centre of the power will often engage in to keep the power imbalance intact. Scarcity is a convenient explanation to favour this imbalance, and those at the centre will often change the rules, or shift the goalposts, suddenly willing to let go of the scarcity. For example, in the wake of the coronavirus lockdown, gay people were allowed to donate blood, likely from a shortfall in blood donations.
It is necessary to understand that so much of the power in the centre—the important positions within medicine, law and education—is held in the hands of upper caste/class cis-het males. Their overwhelming majority in these positions of power also gets reflected on what gets studied, what is considered essential, and what is considered criminal. When criticised, those at the centre will often claim that they never stopped the marginalised from creating knowledge and representing themselves; ironic, since it’s the very othering nature of the system that effectively removes the marginalised from the avenues of education that could help them reach the position of power themselves. It is almost delusional to expect that someone who does not have the power will then decentralise the power and create more knowledge.
In his 2010 paper, “Healthcare: A crisis of artificial scarcity”, author Keith Carson highlighted some important points and also suggested some solutions: “The incentive, both for hospitals and practitioners, is to maximize the number of procedures charged for, which means it is the opposite of their rational interest to inform the patient of his options and their relative cost at the time of the decision.”
It is necessary to understand that so much of the power in the centre—the important positions within medicine, law and education—is held in the hands of upper caste/class cis-het males. Their overwhelming majority in these positions of power also gets reflected on what gets studied, what is considered essential, and what is considered criminal.
He also then expands how, financial problems within these systems are just an add-on. Governments incentivise some disciplines and types of cares over others, those which serve systems of heteronormativity and patriarchy. Those avenues are thus likely to be more affordable due to the research, insurance premiums, and time/attention invested by doctors.
Carson suggests a hybrid approach, where cooperatives should finance health care, in addition to alternative ways of delivering the services. This gets rid of the monopoly that ramps up the prices on everything. Direct patient contact with health care also rids the 25% cost that needs to be given for insurance paperwork.
The paper is full of such insights; however, the solution towards the end suggests eliminating the insurance industry which incentivises high costs. The other solution is that small clinics and hospitals with flat-rate fees and basic physician training which takes care of most concerns with which people approach medical systems. Therefore, along with reduction in specialist care, the costs should come down too. Carson suggests that these smaller primary care structures be run by cooperatives that include patients so that all interests may be well represented.
Furthermore, Carson adds:
Defensive medicine’ would be mitigated by some combination of reasonable caps on punitive damages, contractual waivers of expensive testing under the terms of membership, or placing the burden on the patient to explicitly approve additional tests after being counseled on their costs and benefits; hence absent some clear warning sign to the contrary, Dr. Kling's “empirical” treatment rather than “premium” treatment would be the norm.
This would take care of unnecessary testing and procedures that increase the cost.
Carson speaks from the perspective of the American health care system, which is highly based on the managed care model. However, India still largely functions from a primary health setup. Most of us do not approach large, multispeciality hospitals unless absolutely necessary. It isn’t straightforward to apply these models to India. We need to just fine-tune the existing structure with the suggestions for accountability made by Carson. Our hope is that, in the near future, those who have marginalised identity will not need to have a different set of systems for their healthcare needs, and there would be no such scarcity—real or artificial.
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Aryan Somaiya, Transman, holds a Master's degree in Psychology with specialisation in Clinical Psychology. He is the co-founder of Guftagu Counselling and Psychotherapy (OPC) Pvt Limited. He is a co creator of Queer Affirmative Counselling Practices Resources Manual (QACP). You can find him on Twitter: @AryanSomaiya and Instagram: @imperfect_queertrans_therapist.
Sadaf Vidha (she/her) is a therapist and researcher with five years of experience. She is interested in cross-disciplinary understanding of human behavior at the intersections of mental health, sociology, social justice and economics. In her free time, she likes to read, paint, bake and play with her cats. You can find her on Instagram: @shrinkfemale and Twitter: @randomwhiz.
