The Perils of Democratic Equality in India
In his book “Just Health”, Norman Daniels notes, when we consider social inequalities in developing countries, we generalize that such inequalities are a logical outcome of deprivation and poverty. But rather poor countries produce excellent health results, and there is a significant socio-economic health deficit in the United States, due to race, even after controlling for income, education and insurance levels. 
Similarly, Dr. Michael Marmot argues that a nation’s prosperity does not determine the health and life expectancy of its inhabitants, take for example: Kerala (a State in India) and take for example China, both present good health outcomes despite low incomes. The social processes that lead to this beneficial state of health need not wait for the world order to be changed to relieve poverty in the worst off countries. A social determinants perspective is crucial.
The aim of this essay is to examine a particularly egregious form of social exclusion experienced by a group called ‘Dalits’ in India, and to present how a social determinant, that of ‘occupational rank’ under the umbrella of a social caste structure affects health and well-being throughout life. Excluding the state of Kerala, there exist immense health and human rights violations of the ‘Dalits’ in India.
This paper discusses the Dalit situation through Rawls’ first principle and the difference principle of Justice. Would this particular situation be of special moral importance? Not being of special moral importance denies a community a range of opportunities open to them (Norman Daniels – Just Health – Meeting Needs Fairly – 2008)?
Norman Daniels draws from Rawls’ (1971) definition that health is a ‘natural good’ and adds, that deficits associated with disease and disability reduce the range of opportunity, and to protect the range of opportunities we must protect the socially controllable factors that promote health such as medical services, and distribution of broader social determinants of health. He argues health is not a product of health care but also of other social goods and thus cannot be isolated from broader social justice.
What are Social Determinants of Health
Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Conditions (e.g., social, economic, and physical) in these various environments and settings (e.g., school, church, workplace, and neighborhood) have been referred to as “place.” In addition to the more material attributes of “place,” the patterns of social engagement and sense of security and well-being are also affected by where people live. Resources that enhance quality of life can have a significant influence on population health outcomes.
The most significant evidence on the relation between health outcomes and socially controllable factor comes from the Whitehall studies, conducted in England by Michael Marmot and his colleagues (1978). In these studies, the social determinant of health is occupational rank.  In this paper’s analysis of the ‘Dalits’ in India, the social determinant is also occupational rank, only under the umbrella of a ‘caste system’.
Consider the ’Dalits ’of India & their social determinants of health
Dalits, also known as “Untouchables,” are members of the lowest social status group, or the lowest social rank, in the Hindu caste system. They face discrimination and even violence from members of higher castes, particularly in terms of job opportunities, access to education, and other freedom and liberties. The word ‘Dalit’ means “the oppressed” and members of this group gave themselves the name in the 1930s. A ‘Dalit’ is actually born below the caste system, which includes the four primary castes of Brahmins (priests), Kshatriya (warriors and princes), Vaisya (farmers and artisans) and Shudra (tenant farmers or servants). 
This essay won’t delve into the trials and misfortunes of the Dalits through India’s past, but highlight their plight through a paragraph from Arundhati Roy’s (The Ministry of Utmost Happiness – 2017) book which describes a typical day in a Dalit’s life, in the India of today. Names and places are fictional, events and circumstances are real. It’s her expressive and sensitive description that draws attention to their cause.
Excerpted from “The Ministry of Utmost Happiness” “Saddam Hussain was his chosen name, not his real name. His real name was Dayachand. He was born into a family of Chamars— skinners— in a village called Badshahpur ……One day, in answer to a phone call, he and his father, along with three other men, hired a Tempo to drive out to a nearby village to collect the carcass of a cow that had died on someone’s farm….…We found the dead cow easily. It’s always easy, you just have to know the art of walking straight into the stink.”  They loaded the carcass on to the Tempo and set off for home. On the way they stopped at the Dulina police station to pay the Station House Officer his cut, a previously-agreed-upon sum, a per-cow rate. But that day the officer wanted more not just more but three times the amount.
And their inability to pay ended three lives. The Station House Officer arrested them on a charge of ‘cow-slaughter’ and placed them in the police lock-up. Two hours went by — A few men went into the police station and brought out Saddam’s father and his three friends. Then began the beatings, at first just with fists, and then with shoes. But then someone brought a crowbar, another a car jack and with the first blow, Saddam heard their cries. He had never heard such a sound before. It was a strange, high sound, it wasn’t human.  This is not one isolated or fictional event. Human Rights Watch reports that these incidents happen every day, of every year, to countless ‘Dalits’.
The daily beatings, beltings, floggings and final disposition of the ’Dalits’ are generally not covered by regular news channels, but propelled by the coverage on social media, stories of Dalit-atrocities are pouring fuel on dying ambers. On July 21, 2016, “The Hindu” a very respected Indian newspaper, reported: “For the last three days, Gujarat’s Dalit community has been seething with anger over the public flogging of a group of ‘Dalits’ who were skinning a dead cow in Mota Samadhiyala, a village near Una town in Saurashtra region.
“The four men were brutally beaten with steel pipes and iron-rods, they were later stripped, tied to a SUV and dragged through the main market near the local police station in Una. The flogging was filmed, posted on Facebook as a warning to other Dalits.” 
While ‘Dalits’, together with other tribes, make up nearly 25 percent of the country’s population, the National Human Rights Commission (NHRC) found that the media “provides negligible space to their plight/problems.” Instead, these communities mostly receive attention when the discussion is focused on backwardness, population growth, lack of entrepreneurship and productivity. 
Joseph Campbell, American Professor of literature and mythology wrote, “ …In America we have people from all kinds of backgrounds, all in a cluster, together, and consequently law has become very important in this country. Lawyers and law are what hold us together. There is no ethos.” Similarly in India, there is immense plurality in backgrounds, religions, ethnicity, languages, customs, and traditions. There is no ethos. Can law and lawyers offer a safe home to the Dalits in India?
Could the rule of law, especially Rawls’ “democratic equality” – the combination of fair equality opportunity principle with the difference principle be a good first step for the Dalits?
Discussion: Rawls’ Theory of Justice or Beauchamp Childress’ Four Principles
The first principle requires that citizens enjoy equal basic liberties. The difference principle is the second part of John Rawls’ theory of justice. The difference principle says that inequalities in lifetime prospects (as measured by the index of primary social goods) are allowable if the inequalities work to make those who are worst off as well off as possible compared to alternative arrangements. 
First Principle of equal basic liberties, although necessary, appears impossible to accomplish, given India’s socio-political climate. Let’s consider the report submitted by the Human Rights Watch and the Center for Human Rights and Global Justice (CHRGJ) at New York University School of Law. This joint-submission was based on in-depth Human Rights Watch investigations on caste discrimination in India and the findings of Indian governmental and non-governmental organizations (NGOs) on caste-based abuses.
The Commission wrote: “…the law enforcement machinery is the greatest violator of Dalits’ human rights. According to the NHRC, widespread custodial torture and killing of Dalits, rape, sexual assault of Dalit women, and looting of Dalit property are condoned or at best ignored.”
Challenges to the fortification of Dalits’ human rights are massive. If the domestic institutions and government agencies, the very institutions appointed to ensure rights and freedoms are violators and perpetrators of crimes against the ‘Dalits’, then where should they turn? Indian government has resisted adhering to international norms which they cite as contradicting local cultural or social values.
Additionally, Western countries—especially the United States—resist international rights cooperation from a concern that it might harm business, infringe on autonomy, or limit freedom of speech. The world struggles to balance democracy’s promise of human rights protection against its historically Western identification.
The difference principle says that inequalities in lifetime prospects (as measured by the index of primary social goods) are allowable if the inequalities work to make those who are worst off as well off as possible compared to alternative arrangements. But in the India of today, NHRC reported: “When Dalits organize to protest their discriminatory treatment and claim their rights, (within the allowable social caste structure) the government fails to protect them, and there are retaliatory attacks by upper-caste groups including the rape of Dalit women.” Are the ’Dalits better off because of claiming their rights?
Would the ’Dalits’ be better off, if the inequalities handed out to them – inequalities where their hard earned earnings, their labor of blood, toil, sweat and tears are not brutally stripped away by the Station Officers, Police, and the Judiciary, or their very livelihood becomes a reason for assault and torture? My answer is “Yes”, in the short run.
It appears that Rawls’ theory of Justice is more valid for developed nations than for developing ones, and in a developing country, like India, with little history of organized labor movements and institutions that safeguard rights of workers, ’Dalits’ remain worse off even allowing for inequalities.
Could resetting priorities in legal settings improve the situation?
Would the ’Dalits’ be better off if the laws were restructured and reordered? Instead of granting equal rights or some “reservation” status to the ‘Dalits’, there would be a restructuring of laws that would forbid the higher caste Hindus from trampling the rights of the ‘Dalits’ or for that matter all citizens. That forbidding the higher caste Hindus from violating the rights of all citizens, would take precedence over all other rights. Nations that are void of strong civil institutions and ethos and lack a sense of ‘do no harm’ to others, need to adopt this one basic moral principle. The law must apply to all citizens, including the judiciary and the law enforcement. Beauchamp Childress’ Four Principles
Beauchamp and Childress’ Four Principles is one of the most widely used frameworks and offers a broad consideration of medical ethics issues, not just for use in medical ethics but also for a universal common morality. These four principles are: respect for autonomy, beneficence, no maleficence, and justice. Beauchamp and Childress believe that their approach to manage ethically difficult cases is cross cultural i.e., it can be used in different cultures such as American, European, and Asian. 
Beauchamp thinks that people in all cultures grow up with knowledge of some basic moral rules and an understanding of which demands that these rules be applied to all. This body of basic moral rules constitutes morality in all cultures and Beauchamp calls this shared universal system of precepts the common morality or morality in the narrow sense. From this point of view, there is no difference in basic rules of morality in America, Denmark, Italy, China, and Japan (and India). According to Beauchamp the “object of morality is to prevent or limit problems of indifference, conflict, hostility, scarce resources, limited information, and the like”.  Could the inclusion of Beauchamp- Childress’ Four Principles in the Indian Constitution, before any other social guarantees, offer some relief to the confounding caste structure?
Indian Constitution and Reality
Is a reduction in conflict, hostility and cruelty in a country such as India, possible, where it is said: “… the police are increasingly becoming a threat to the Rule of Law’’. And the politicians perceive a divinity of sorts, deeming themselves as being above the Law.
To avoid inequities and to guarantee fundamental liberties of a person, India has a very comprehensive Constitution: Article 14 of the Indian Constitution provides for equality and Article 21 of the Indian Constitution bestows protection of life and personal liberty.  Yet, widespread violation of human rights and liberties are the norm of the day.
In light of Daniels’ view that health is not a product of health care but also of other social goods and thus cannot be isolated from broader social justice, necessity of adopting Beauchamp & Childress’ four principles cannot be emphasized enough. The four principles could be applied to all individuals and Institutions, especially the very instruments of governance.
For any right to fundamental liberties and guarantees of equality to succeed, including a program that allows inequalities so that the conditions of the worst off may improve, the principle of Nonmaleficence (Do no harm) should precede all others. Can we close such a vast gap in social structure and promote justice, for the sake of health and equal opportunity? Could Beauchamps’ principle of morality be an answer to this unimaginable inequity? If supported by institutions of global justice, it’s worth a try.
In India of today the aggravation is in granting the ‘Dalits’ their reservation rights in lieu of past injustices, which only work at amusing the Station Officers, looking for their cuts from the Dalits (Arundhati Roy 2017) —the so-called reservation status simply adds to the hostilities, and ethnic violence. Therefore, support from the global institutions of justice is essential. Unless an International institution compels the global community to make basic human rights absolutely paramount and business interests secondary, hearings and reports by Commissions would remain ineffective and pointless.
In surveying the Dalit situation, it appears, that neither Socratic justice, nor Egalitarianism but inclusion of Beauchamp & Childress’ four principles to the Indian Constitution along with a system of global governance be a new International Health and Human Rights watch agenda.
 Daniels, Norman. 2008. Just health: meeting health needs fairly. Cambridge: Cambridge University Press. (Page 79)
 Marmot, M et al (2008): Closing the gap in a generation: health equity through action on the social determinants of health. Lancet, 372: 1661-69.
 Ibid Page 21
 Ibid Page 22
 The Institute of Medicine. Disparities in Health Care: Methods for Studying the Effects of Race, Ethnicity, and SES on Access, Use, and Quality of Health Care, 2002.
 Roy, Arundhati. 2017. The Ministry of Utmost Happiness. [S.l.]: Penguin books India.
 Ibid (1362 of 6459 – Kindle Book)
 National Human Rights Commission (NHRC) NHRC Report, Section VI, p. 134
 Campbell, J., & Moyers, B. D. (2005). Joseph Campbell and the power of myth with Bill Moyers. New York, NY: Mystic Fire Video.
 Rawls, John. 2005. A theory of justice. Cambridge, Mass: Belknap Press
 Ebbesen M, Andersen S, Pedersen BD (2012) Further Development of Beauchamp and Childress’ Theory Based on Empirical Ethics. J Clinic Res Bioeth S6:e001. doi:10.4172/2155-9627.S6-e001