Caste Out—Navigating Caste Discrimination in Health Care Employment
This Bulletin is brought to you by AHLA’s Labor and Employment Practice Group.
- February 28, 2024
- Jenna Brofsky , Husch Blackwell LLP
- Catarina Colón , Husch Blackwell LLP
Caste discrimination in health care employment is a concerning issue that influences workforce dynamics and, consequently, patient care. “Lower” caste individuals may face barriers in accessing health care-related employment opportunities, limiting their representation within the sector. This lack of diversity can lead to an environment where discriminatory attitudes persist and affect both workplace culture and patient interactions.
What is Caste?
“Caste” or a “caste system” is a social hierarchy passed down through families and can dictate an individual’s permissible professions as well as aspects of their social life, including whom they can marry. It exists in a variety of ways, but for purposes of defining a legally protected class, it most directly relates to persons of South Asian descent. Importantly, however, an individual’s race or religion is not a caste, and caste and race/religion should not be equated or conflated.[1]
There are typically four main castes: (1) Brahmins (priests, academics); (2) Kshatriyas (rulers, administrators, warriors); (3) Vaishyas (artisans, tradesmen, farmers, merchants); and (4) Shudras (manual laborers). The caste system completely excludes Dalits (street cleaners, those who perform menial tasks). As with other discriminatory practices among privileged classes, Brahmins—the most dominant caste—are few and far between whereas Dalits make up the most populous caste. Dalits broadly encompass the most oppressed individuals, perceived as socially and intellectually inferior, subjected to the most exploitative jobs.
The 1965 Hart-Cellar Act revamped immigration policy in the United States and paved the way for increased Asian immigration with an express preference for professionals. The dominant castes in South Asia are those with privileged access to education and white-collar jobs (such as doctors and engineers), which has led to an overrepresentation of dominant castes in the United States as compared to the South Asian population at large.[2] The professional successes of members of dominant castes in the United States workforce have unfortunately created conditions for bias and discrimination against medical practitioners that come from “lower” castes.
Caste Discrimination in Employment
Workplace discrimination based on protected characteristics has long been prohibited by Title VII of the Civil Rights Act, the primary federal law on this topic. Two cities—Seattle and Fresno—now have laws that explicitly address and prohibit caste discrimination in employment. We anticipate that jurisdictions with large South Asian populations, such as New York, New Jersey, Texas, and Illinois, may consider enacting similar legislation. Notably, how each jurisdiction ultimately defines caste in legislation will affect resulting interpretations and application of the law. Debates over the definition of caste continue regarding the intertwined nature of the history of caste with race, national origin, and religion, and the extent to which an employee could bring a claim of discrimination on one, or all three, of those bases.
Unlawful discrimination can manifest in various forms, including unequal opportunities for career advancement, disparities in salary and benefits, and harassment. These challenges can create a hostile work environment for lower-caste employees, impacting their professional progression, job satisfaction, and mental health and well-being.
As an example, one cardiologist whose last name has origins from a small village in India, provides anecdotes of uncomfortable interactions with colleagues. The physician recalled experiences where other medical professionals mocked his last name, questioned his caste, and made comments such as, “Well, you are a physician now despite being born in a lower caste. This makes you higher instantly.”[3] While these comments are hurtful and unprofessional, they may also rise to the level of unlawful harassment if not quickly addressed and remedied by leadership. Other examples of workplace bullying against “lower” caste members in the medical profession include being denied the chance to perform certain surgeries, being treated as intellectually inferior, and being asked “What is your Caste?” when meeting a colleague for the first time. These experiences often begin during medical school and can persist through an individual’s employment, as is evident by the foregoing personal experiences shared.[4]
Best Practices for Health Care Organizations
Given the high demand to recruit and retain health care professionals in the United States, employers cannot afford to take a backseat with respect to creating welcoming environments for practitioners from all backgrounds. This is particularly true given that, according to data from the American Physicians of Indian-Origin (AAPI), Indian Americans make up 9% of all physicians in the country, meaning that one in seven medical practitioners in the U.S. is of Indian descent.[5]
Fortunately, health care institutions can take steps to help mitigate caste discrimination in their workforce by taking the following steps:
- Include language in your policies that state the Organization does not tolerate discrimination or retaliation against personnel under any circumstances, and that engaging in such behavior may result in discipline, up to and including termination;
- Ensure you have a formal complaint procedure that provides clear direction for individuals that experience or witness discrimination;
- Take every complaint of discrimination, harassment, or retaliation seriously;
- Regularly train all personnel on the Organization’s anti-harassment and anti-discrimination policies and practices, and consider providing additional training on bias, cultural competency, and psychological safety in the workplace;
- Consider explicitly listing caste in your anti-discrimination policy, particularly if you are in a jurisdiction that expressly includes caste as a protected characteristic, and include a definition of caste that is not limited to individuals of Indian descent or those individuals of a particular religion or national origin;
- Spread awareness by educating human resource professionals, managers, and leadership about caste discrimination, and how to identify and respond to suspected incidents of caste discrimination or bias.
The cost of failing to address any form of harassment or discrimination in the workplace can result in significant risk including legal repercussions, personnel turnover, and reduced employee and patient morale. In sum, caste discrimination in health care is a multi-faceted and complex issue encompassing barriers to access, biases among health care providers, socioeconomic challenges, and pervasive social stigma. Addressing these challenges requires a comprehensive approach involving organizational leadership, policy review, and education to foster an inclusive health care system for all.
[1] This article provides only a high-level, simplified overview of the history and definitions of different castes, which are extremely complex and multifaceted subjects. In addition, this article addresses only caste discrimination in the context of employment and not patient care.
[2] “Caste Discrimination Exists in the U.S., Too—But a Movement to Outlaw It Is Growing,” by Rohit Chopra and Ajantha Subramanian, Time Magazine, February 11, 2022.