TWO evocative and tangible manifestations of the idea of dignity have recently made history and, in doing so, captured the public imagination. The first was the seminal chant of Tunisian youth as they took to the streets, crying ‘dignity before bread’, in the process throwing an entire region in social disarray. The power of the chant showed that it was neither poverty nor jobs but a quest for dignity which was fuelling action. It is this that the politicians and policy makers suddenly woke up to.

The second was the eloquent judgment by Justice Anthony Kennedy of the Supreme Court of the United States legalizing same sex marriage.¹ Most now agree that the idea of dignity is what constitutes the philosophical foundation of the judgment. The resulting social and political potency of each of these manifestations has moved the idea of dignity so far confined to intangible rhetoric and by implication, not as relevant to public policy, to one that directly affects policy regimes.

This essay is about dignity and what it adds to the discourse on inequality and social exclusion. It presents four propositions as examples of why dignity matters in public policy, especially for highly unequal contexts. In doing so it takes forward the narrative constructed in the report, ‘Inclusion Matters: The Foundation for Shared Prosperity’ that focuses on the flip side of social exclusion – social inclusion.² The report brought the idea of dignity into the mainstream lexicon of the World Bank as it defines the amorphous notion of social inclusion as ‘the process of improving the ability, opportunity and dignity, of persons disadvantaged on the basis of their identity, to take part in society.’

 

Excluded groups are systematically, though not always deliberately, subjected to humiliation and indignity. It is in fact one of the most visceral ways in which inequality and exclusion play out. In some cases naming, especially when it becomes name-calling, could be a form of indignity. Persons with a disability may be known in their village or neighbourhood by the name of the disability. In other cases, they may be known by their caste, their race, their sexual orientation or their occupation – often hurled as a pejorative or an insult. In still other cases, bullying strips individuals of dignity and treads a fine line with physical violence. Schools the world over are hotbeds of bullying and abuse for students who do not conform in some way. To sum up, this essay moves from the notion that dignity is not only an important moral imperative, or a basic human right, but that it has implications for public policy and is central to the process of social inclusion.

‘…affirmations of human dignity (in the post-World War II international charters and national constitutions) reflect a political consensus among groups that may well have quite different beliefs about what human dignity means, where it comes from, and what it entails. In effect, "human dignity" serves here as a placeholder for "what-ever it is about human beings that entitles them to basic human rights and freedoms".’

– A. Schulman, 2008³

‘Politicians and activists across the political spectrum invoke dignity as part of their rhetoric in advancing various goals… Everyone is understandably in favour of dignity, even if they disagree about what it requires.’

– N. Rao, 2008⁴

 

The Latin word dignitas from which the word dignity is derived, literally means ‘worth’. While the notion of dignity is best known in development literature for its use in international charters of human rights and its mention in innumerable constitutions, the idea of dignity has in fact a long history in western social philosophy. Schulman⁵ traces four clear streams of thought that have influenced the modern notion of dignity: streams that are rooted in classical antiquity, in Biblical scripture, in the social thought of Immanuel Kant and finally, in international conventions and national constitutions after World War II. Most agree, however, that the idea of dignity, just as ideas of equality and freedom, leaves much to interpretation and that often there are tensions between competing understandings of the idea. The Preamble to the Constitution of India mentions human dignity and the courts have in many cases used this as an anchor to make liberal pronouncements to safeguard the interests of those who may be at risk of exclusion.⁶

 

The historical journey of the idea of dignity is not the subject of this essay. This short section only serves to highlight the point that ‘dignity’ has roots which go back into antiquity and that its usage in the modern context is often fraught with disagreement. Suffice it to say that when international resolutions and declarations refer to ‘respect for the inherent dignity of the human person’, they invoke ideas of ‘esteem’, ‘deference’, ‘regard for’ and ‘recognition of’ a person’s own sense of self-worth.⁷

Two major strands of the contemporary literature on dignity have a direct bearing on public policy, although various other philosophical traditions also elaborate on the notion. The first comes from the public health literature, or more narrowly, from bioethics, and the second from case law and legal writings about dignity. Current issues in bioethics, especially in western countries, are related to the dignity of older persons, particularly those in nursing care, of persons with serious disabilities, of persons who are in hospice. Other philosophical conundrums focus on stem cell research and abortion, among other issues (that often become quite political). This literature is most prolific in the United States, but also in Canada, UK and Australia. Of late, research on ageing with dignity and death with dignity have acquired the kind of importance that has led to funding from the National Institutes of Health and a dedicated programme sponsored by the US President’s Council on Bioethics.

I mentioned the fact that dignity is more prevalent in the language of public policy now than it has perhaps ever been before and that two concrete manifestations referred to earlier – the Arab Spring and the recent judgment in favour of same sex marriage in the United States – had a part to play. But the idea of dignity in public policy clearly precedes these two developments. Here I present four propositions as examples to highlight the relationship between dignity and public policy outcomes – two from the health sector, one from the area of sanitation and the last from education. While these propositions draw upon some global evidence, I apply them to current policy issues in India. In each case, exclusion based on caste and tribe is salient.

 

Proposition 1: Dignity matters for maternal health. A recent World Bank report highlights the example of Adivasi women, who have a much lower probability of giving birth in health facilities,⁸ when compared to their non-Adivasi counterparts.⁹ When the National Family Health Survey 2005 (NFHS) asked those women who had not given birth in health facilities in their last birth, why they had not done so, almost three quarters of Adivasi responses indicated that they did not think it necessary. This was somewhat surprising because we would have expected the supply of health services, or poverty, or remoteness, or lack of transportation to more likely have been implicated. Indeed these were cited, but not as strongly as the set of responses that pointed to the fact that these women did not consider it necessary.

The report tries to unpack this ‘not necessary’ response to understand what may be going on. It triangulates this response with micro studies about the delivery of health care in Adivasi areas and concludes that this so-called lack of demand may in fact be a function of the quality of supply of healthcare. And by quality of supply, the report does not mean predictability or provider availability, but rather the manner in which health providers behave with Adivasi patients. It draws from a similar example of indigenous women in Peru to suggest that Adivasi women who do not use health centres may in fact be rejecting the indignity with which they are treated and the disrespect accorded to their culture and knowledge systems.

 

Why does this matter? It matters because dignity is both a right of Adivasi women and a duty that providers should be expected to discharge. But it also matters because the uptake of maternal health services by Adivasi women has a bearing on their own health and for maternal health outcomes for India as a whole. Unless Adivasi women are treated with dignity and respect, they may well continue to reject a health system that they do not trust and Adivasi areas may continue to lag behind in the uptake of maternal health services. Further, since India accounts for almost two-fifths of global maternal mortality, this has an impact far beyond that for India alone.¹⁰ Therefore, in order to reduce maternal mortality in India as a whole, the dignity of Adivasi women is as important as the technical quality and predictability of services in Adivasi areas. The World Bank study draws from the literature that has emerged from the nursing and the social work practice in the United States to show how providers can be trained and held accountable, not just for their technical skills but also for their ‘cultural competencies’.¹¹

 

Proposition 2: Violence is an extreme form of indignity and it matters for human development. One of the direst manifestations of indignity is the use of violence against a person or group that is considered weaker in some way. Violence against women is a case in point. A World Bank report showed a relationship between the use of antenatal care facilities and lifetime experience of spousal violence.¹² It draws on the NFHS 2005/6 to show that nearly one-third of Indian women experienced spousal violence at some point in their lives. Nearly 81 per cent of women who had never experienced violence reported receiving antenatal care in the NFHS 2005/6 in contrast to only 67 per cent among women who had experienced violence.

At the multivariate level too, women who had experienced violence showed poorer outcomes, after controlling for a number of household and individual characteristics, including ability to reach a health centre and whether distance to a health centre was a problem. In addition, women who had experienced violence were one and a half times more likely to have had a terminated pregnancy or still birth. Their children were 1.14 times more likely to be stunted than children of mothers who had not been abused. Clearly, state intervention to prevent spousal violence is important in itself, but it also matters for human development outcomes of women and their children.

 

Proposition 3: A national sanitation programme matters for access, but it also matters for dignity. India’s renewed push towards total sanitation, through the Swachh Bharat Mission presents another opportunity for the advancement of dignity. Last year, on World Toilet Day, Junaid Ahmad and Caren Grown blogged that while toilets are of course good development, they are also about the dignity of those women and girls who are forced to defecate and urinate in the open with no privacy even when they are menstruating.¹³ I would extend that to say toilets are of course good development, but they are also about the dignity of manual scavengers, who are forced to engage in a pervasive and egregious practice, although it is unclear just how many people are affected. This practice should have been history years ago but it was only in 2013 that the comprehensive Prohibition of Employment as Manual Scavengers and their Rehabilitation Act was passed.¹⁴

The government, with strong pressure from Dalit activists and the Safai Karamchari Union, has taken cognizance of the fact that the draconian rules of purity and pollution, which condemn certain castes to humiliating practices, need to be simultaneously dismantled as part of the national Swachh Bharat Mission. Some would argue that this instrumental approach to dignity is a cop-out, which in many ways it is; yet, unless policy makers realize the importance of indignity as a barrier to the achievement of policy goals, chances are that interventions to address the issue will remain peripheral and unenforced. And today, the Swachh Bharat Mission of the government provides an opportunity not just for better sanitation, but also for transformative social change.

 

Proposition 4: Bullying and humiliation in schools constrain the achievement of education outcomes. Let us now turn to schools where, globally, a number of practices heap indignity, humiliation and fear among students considered ‘weak’ or those who do not conform. Such indignity can play a crucial role in depressing educational outcomes. Various studies in the US and other countries have focused on forms of bullying and some have even tried to calculate the costs of bullying and harassment in schools, arguing that ‘when students feel emotionally or physically unsafe, attendance and grades can fall because of actual or psychosomatic illnesses, elective truancy, or dropping out. An increasingly negative climate can also lead to more vandalism as students look for an outlet to express their frustration, powerlessness, despair, anger, or fear.’¹⁵

A national school climate survey of self-reported sexual minority students in the US showed that those who had experienced high levels of in-school victimization based on their sexual orientation or gender expression also had poorer health and educational outcomes. Additionally, they had poorer grades and lower likelihood of pursing higher education. Finally, they were about three times as likely as other students to have missed school in the past month because of safety concerns, were less likely to feel a sense of belonging to their school community, and had lower levels of self-esteem and higher levels of depression and anxiety.¹⁶

 

In India as well, some micro studies have pointed to forms of humiliation of Dalit students or students with disabilities, or even students who do not speak the mainstream language with ease. For instance, Nambissan’s careful ethnographic work highlights both the insidious and overt ways in which Dalit students are humiliated. She recounts such practices as preventing Dalit students from accessing facilities like water, differential participation in the classroom and in teachers’ assignment of responsibilities to students and differential teacher attention and support. Other forms of indignity include selective segregation of Dalit students, their overall silencing, through identification and naming. Both non-Dalit students and teachers may be complicit in these forms of humiliation.¹⁷ In another study, Hoff and Pandey used controlled experiments in a village in Uttar Pradesh where Dalit and non-Dalit junior high school students were asked to solve puzzles (mazes). While there was no difference in outcomes between the two groups of students to start with, the outcomes for Dalit students steadily worsened as their caste identity was made salient, indicating that the act of naming and then of segregation have deleterious consequences for excluded groups.¹⁸

 

The previous sections argued that the dignity should be centre-stage in the policy discourse and that there are concrete actions that can be taken to advance it and, in the process, help achieve better social policy outcomes. This is, however, not a simple undertaking. Applying the idea of dignity to law or policy is fraught with controversy due to two main reasons that complicate the issue. First, the lack of a common understanding or a universal notion of dignity makes its application subjective and amorphous and, hence, controversial. A second and related issue is that like equality and freedom, concrete manifestations of the idea of dignity inevitably bleed into power relations. Indignity is about assertion of power and about showing an individual or an entire group that is supposedly lower in the social hierarchy ‘their place’. Conversely, dignity is about equality and social inclusion. All three – dignity, equality and social inclusion – are inherently political.

Regardless of the challenges in the application of the idea of dignity, change has taken place the world over and examples abound. The US Constitution has decreed racial equality and racist epithets that were once accepted usage are now considered slurs. The 2013 World Bank report cited earlier points out that foot binding in China has been abolished and various other practices that kept excluded groups ‘in their place’ are now considered unacceptable. Like other countries, India has also seen sustained occupational and social mobility and many egregious practices are now extinct.

 

In short, the fact that values and the normative foundations of exclusion and discrimination have undergone substantial change over the years is testimony to their mutability and amenability. The more complex question is – What are they amenable to? When and how can egregious forms of indignity be considered unacceptable? Do attitudes change first or do they follow behaviours? What enables change in behaviours? Is there a threshold after which changed behaviours become the norm? Who drives the change – individuals, groups or the state? How do societies move from a norm where certain excluded groups are treated with indignity to one where they are given the respect and dignity that is due to all citizens?

The literature on social change points to three discrete actors that propel change – excluded groups themselves through collective action; the state as the preeminent and most influential arbiter of change and third party actors such as elites, civil society, unions and other collectives who advocate on behalf of excluded groups.¹⁹ Ideally, we need some combination of all three.

 

* Views expressed here are personal and in no way attributable to the World Bank Group or to its shareholders. Discussions with Moeena Das and comments from Soma Ghosh Moulik, Sabina Espinoza and Ieva Zumbyte are gratefully acknowledged.

Footnotes:

1. http://www.supremecourt.gov/opinions/14pdf/14-556_3204.pdf

2. World Bank, Inclusion Matters: The Foundation for Shared Prosperity. The World Bank, Washington, DC, 2013.

3. A. Schulman, ‘Bioethics and the Question of Human Dignity’, in Human Dignity and Bioethics: Essays Commissioned by the President’s Council on Bioethics. The President’s Council on Bioethics. Washington, DC, 2008. https://bioethicsarchive.georgetown.edu/pcbe/reports/human_dignity/chapter1.html(accessed 7 July 2015).

4. N. Rao, ‘On the Use and Abuse of Dignity in Constitutional Law’, Columbia Journal of European Law 14(2), 2008, pp. 201-256.

5. Op cit., fn. 3.

6. http://lawmin.nic.in/olwing/coi/coi-english/Const.Pock%202Pg.Rom8Fsss(3).pdf

7. O. Schachter, ‘Human Dignity as a Normative Concept’, American Journal of International Law 77(4), 1983, pp. 848-854.

8. I do not suggest that institutional delivery is the answer to lowering maternal deaths. The example is used to show the rejection of health services and not to argue for more institutional births.

9. In the NFHS 2005, less than 20 per cent of Adivasi women, compared to 40 per cent of all women gave birth in health centres (World Bank 2013). Kumar and Gupta report, based on District Level Household and Facility Survey 2007-08, find that 38 per cent of Adivasi women compared to 66 per cent of ‘other’ women have access to safe delivery. See P. Kumar and A. Gupta, ‘Determinants of Inter- and Intra-Caste Differences in Utilization of Maternal Health Care Services in India: Evidence from DLHS-3 Survey’, International Research Journal of Social Sciences 4(1), 2015, pp. 27-36.

10. P. Kumar and A. Gupta, ibid.

11. J. Clark, ‘Defining the Concept of Dignity and Developing a Model to Promote its use in Practice’, Nursing Times 106(20), 2010, early online publication. http://www. nursingtimes.net/nursing-practice/specialisms/practice-nursing/defining-the-concept-of-dignity-and-developing-a-model-to-promote-its-use-in-practice/5015026.article (accessed 7 July 2015).

12. World Bank, Poverty and Social Exclusion in India. World Bank, Washington, DC, 2011.

13. A.K. Junaid and C. Grown, ‘World Toilet Day: The Link between Gender Equality and Sanitation.’ The World Bank Water Blog, 2014. http://blogs.worldbank.org/water/world-toilet-day-link-between-gender-equality-and-sanitation (accessed 7 July 2015).

14. Analysis and Recommendations in the Context of The Prohibition of Employment as Manual Scavengers and their Rehabilitation Bill, 2012. http://www.dalits.nl/pdf/Prohibi-tionOfEmploymentAsManualScavengers.pdf

15. R. Phillips, ‘The Financial Costs of Bullying, Violence and Vandalism.’ 2010. (Web only) Principal Leadership11(1).http://www. nassp.org/Content.aspx?topic=The_ Financial_Costs_of_Bullying_Violence_and_ Vandalism_Web_only_(accessed 1 July 2015).

16. Kosciw et al. 2012 cited in World Bank 2013, op. cit., fn 2.

17. G.B. Nambissan, Exclusion and Discrimination in Schools: Experiences of Dalit Children. Working Paper Series Vol. 1, No. 1. Indian Institute of Dalit Studies and UNICEF, 2009. http://dalitstudies.org.in/wp/wps0101. pdf (accessed 7 July 2015).

18. K. Hoff and P. Pandey, ‘Belief Systems and Durable Inequalities: An Experimental Investigation of Indian Caste.’ Policy Research Working Paper 3351, The World Bank, Washington, DC, 2004.

19. M.B. Das, ‘Exclusion and Discrimina- tion in the Labour Market.’ Background Paper for the World Development Report 2013, The World Bank, Washington, DC, 2013.