Inherited Pain: How sickle cell reveals the intergenerational violence of caste

In conversations around structural violence in India, caste is often treated as a social artefact, historical, unfortunate, but supposedly withering away under the weight of modernity. The post-liberalisation imagination celebrates mobility, development, and access, even as the material realities of marginalised communities remain shaped by neglect, deprivation, and premature death.

What does it mean for a system of oppression to persist not only in memory or social customs, but in bodies?

What happens when centuries of exclusion begin to calcify, not just in landlessness, in hunger, in denied education, but in blood, in DNA, in inherited illness?

There are violences that do not announce themselves through lynchings or slurs. Some arrive quietly, through policy apathy. Through silence in textbooks. Through the normalisation of suffering. Through state indifference.

And some, we only begin to see when they appear at our doorstep.

Illness often arrives without vocabulary.

We speak of fatigue, of pain, of the body’s betrayal, but language rarely catches up to what the body endures. My cousin, a child no older than ten, moved through years of unnameable discomfort. Fevers that lingered. Limbs that ached without reason. Days that seemed too heavy for his small frame. The explanations were fragmented, clinical, and inconclusive.

No one used the word “genetic.” No one mentioned “inheritance.”

In the weeks following his death, I found myself drawn almost obsessively to the internet. I typed “sickle cell” into the search bar without knowing what I was looking for. Without knowing, really, what I was grieving.

I read as if reading could undo something.

Each article offered a new layer of vocabulary, but none could make sense of the silence that had preceded the diagnosis. Or the quiet with which we accepted it. Sickle cell, I began to realise, was not simply a medical condition. It was a condition shaped by everything we were never told. About the body. About history. About structural violence that chooses not to announce itself.

Understanding Sickle Cell Disease

Sickle Cell Disease (SCD) is a hereditary blood disorder caused by a mutation in the gene that encodes haemoglobin- the oxygen-carrying component of red blood cells. In individuals with SCD, red blood cells become crescent-shaped, sticky, and rigid. These deformed cells struggle to pass through blood vessels, leading to blockages that cause severe pain, organ damage, and increased risk of infection. It is a chronic, life-shortening illness, with no known cure outside of a bone marrow transplant- a procedure both expensive and largely inaccessible to most patients in India.

Classified by India’s Ministry of Health as a major public health challenge, SCD primarily affects populations in central and eastern India, with high prevalence reported in Madhya Pradesh, Chhattisgarh, Maharashtra, Odisha, and Jharkhand. However, what makes this pattern more than a geographical coincidence is its demographic specificity: over 70% of all reported cases are found among Scheduled Tribes, with Scheduled Castes and Other Backward Classes comprising a significant proportion of the remaining affected population.

This is not incidental. It is not random. It is patterned.

According to epidemiological studies, the SCD trait evolved thousands of years ago as a protective genetic response to malaria. Carriers of the sickle cell trait (those with one copy of the gene) were more likely to survive malaria in high-risk zones. Over time, this trait became concentrated in populations living in forested, low-lying, high-malaria areas. In India, these were, and remain, the regions inhabited by Adivasi and Dalit communities, either through traditional settlement patterns or caste-based spatial exclusion.

But the trait that once functioned as a form of biological resistance has, in a postcolonial, casteist state, become a slow death sentence.

A condition shaped by evolution now intersects with structural abandonment. And inherited pain becomes not only biological, but political.

Caste and Environmental Determinants of Health

The geography of caste is not incidental. It is deliberate, spatialised violence.

Historically, Dalit and Adivasi communities have been excluded from clean, resource-rich, and “upper-caste” localities, pushed instead to the peripheries of villages, into forest edges, floodplains, and malaria-ridden lowlands. These were not merely inconvenient locations. They were zones of environmental precarity, lacking access to sanitation, clean water, food security, and healthcare infrastructure. What we now identify as “malaria-endemic regions” were, and remain, the forced homelands of the oppressed.

This spatial segregation was not merely economic. It was caste-based and codified.

The presence of sickle cell disease among some Muslim populations in India is not an anomaly, but a further indictment of caste’s pervasive reach. Many among the Scheduled Castes and Scheduled Tribes historically embraced Islam in pursuit of dignity and personhood denied to them by the Hindu caste order. The gene did not convert; the body carried its history into another faith.

In Dr. Ambedkar’s analysis, caste operates as a mechanism of residential and occupational immobility: it fixes people into inherited roles, not only within the labour market, but within the physical and biological landscapes of India.

Marginalised communities did not “choose” to settle in disease-prone areas. They were confined there. Denied safe spaces, decent housing, or any meaningful choice over where or how they lived, these populations became the ecological subjects of a caste state—made to survive in environments marked by contamination, exposure, and neglect. The adaptive emergence of the sickle cell trait among Adivasis and other oppressed groups is thus not a random evolutionary outcome. It is a biological footprint of structural violence.

This is the terrain where caste and health intersect: not as metaphor, but as geography. Bodies are shaped by landscapes. And in India, landscapes are shaped by caste.

Intergenerational Impact of Caste-Based Oppression

Sickle Cell Disease (SCD) is a hereditary blood disorder caused by a mutation in the hemoglobin gene. This genetic trait is transmitted from parents to their children, making the burden of the disease not merely individual, but familial and generational.

Just as radioactive fallout from Hiroshima and Nagasaki irreversibly altered the genetic futures of those exposed, and just as the Bhopal’s Union Carbide Gas Tragedy continues to shape birth defects and chronic illness decades after its occurrence, caste-based violence in India produces a slow violence- invisible, cumulative, and intergenerational. Sickle Cell Disease, when mapped onto the cartography of caste, reveals how historical oppression becomes biological inheritance. The consequences of being denied access to sanitation, nutrition, health infrastructure, and dignified habitat are not limited to those who endured them directly. They are inscribed into the bodies of their descendants, passed down like an invisible scar.

This is where Dr. Ambedkar’s warnings remain urgent. In his advocacy for constitutional morality, he argued that political democracy without social democracy is hollow. Without addressing the deeply entrenched inequalities of caste and economic exclusion, the Indian state would become a shell, a republic of formal equality and lived inequality.

To Dr. Ambedkar, social democracy was not merely a question of tolerance or reform. It was a structural reconfiguration- a radical shift in how dignity, rights, and life itself are distributed. In this, Dr. Ambedkar anticipated many of the concerns that political theorists like Michel Foucault would later term biopolitics: the management of populations, the governance of health, and the use of state power to decide who lives, who dies, and who is left to die slowly.

Foucault’s framework illuminates how the Indian state engages in caste-based biopolitics, not through direct violence alone, but through calculated neglect. The failure to screen, diagnose, treat, or even acknowledge the burden of Sickle Cell Disease among SC/ST/OBC communities is not a failure of capacity, it is a failure of political will. It is a form of statecraft, where the suffering of some lives is normalised, anticipated, and administratively absorbed.

These are not merely biological tragedies. They are political outcomes.

Challenging the Myth of a “Casteless Society”

The assertion that caste no longer exerts influence in contemporary India is not merely ahistorical. It is an ideological construct that functions to obscure enduring structures of social stratification and oppression. The prevailing discourse of a “casteless society” claims the nation has transcended caste through modernization, economic growth, and legislative safeguards. Yet, this narrative is premised on selective amnesia, privileging surface-level markers of progress while concealing the pervasive and systemic inequalities that persist.

Epidemiological data on the disproportionate burden of Sickle Cell Disease within Scheduled Castes, Scheduled Tribes, and Other Backward Classes provides incontrovertible evidence that caste continues to determine life chances in profound and biologically embedded ways. These disparities are not accidental or incidental; they are symptomatic of entrenched patterns of exclusion that mediate access to healthcare, sanitation, nutrition, and dignified living conditions- social determinants foundational to health outcomes.

The rhetoric of caste obsolescence also rests on a fallacy of exceptionalism, where isolated instances of upward mobility are extrapolated to signify the dissolution of caste hierarchies. This selective narrative masks the broader structural realities in which the vast majority remain constrained by the institutionalized mechanisms of caste domination. It is a discourse that legitimizes the status quo by rendering invisible the systemic deprivation endured by marginalized communities.

Such denialism is not innocent. It performs a deliberate political function: to cleanse the conscience of the modern Indian state, to arrest the momentum for radical redistribution, and to ensure that the scaffolding of caste remains intact beneath the veneer of constitutional morality. It evades the fundamental truth that caste is not an archaic residue, but an organising principle of the Indian social order, structuring labour, access, dignity, and now, even the very biology of survival. It is neither an exception nor a deviation; it is the rule. So long as its presence is denied, its consequences will continue to be naturalised, etched into the bodies of the oppressed, transmitted across generations, and legitimised through silence.

To insist that caste is a relic is to participate in a wilful epistemic violence, a refusal to recognize how caste’s legacies are inscribed onto bodies, environments, and opportunities. The myth of a casteless society must be dislodged if we are to confront the real, embodied consequences of caste and chart pathways toward structural justice and health equity.

Conversion, Education, and the Right to Health

If disease has become the hereditary burden of the oppressed, then emancipation must begin by rejecting the fatalism that has naturalised this inheritance. One cannot excise a gene, but one can dismantle the social order that imbues it with stigma, silence, and disposability.

As Babasaheb Ambedkar insisted, the path to liberation is not paved through endurance, but through rupture. “We do not accept your idea that we were born to suffer,” he declared. Conversion- for Dr. Ambedkar- was not simply a spiritual act, but a categorical rejection of a social system that had dehumanised entire communities. In the context of sickle cell disease, this insight retains profound urgency. To reject caste is to reject the logic that renders certain bodies more exposed to pain, and less entitled to care.

Dr. Ambedkar’s emphasis on education, likewise, was not limited to literacy or employability, but to the cultivation of critical consciousness. Public health must be reclaimed as political education: a domain where oppressed communities learn to read their bodies as texts of history, to interpret pain as political, and to demand collective redress. Medical interventions alone are insufficient. Without structural reckoning, healthcare becomes another terrain where caste reproduces itself, through unequal diagnosis, delayed treatment, and neglect.

Yet the struggle for health equity cannot proceed through isolated reforms. It must be forged in the crucible of social movement. Systems of oppression are not siloed; they intersect and amplify. Caste, gender, indigeneity, and poverty do not merely coexist- they co-produce vulnerability. A rural Adivasi child with sickle cell disease is not “just” a patient; she is the subject of multiple exclusions that converge in her very flesh. The SC or ST woman, doubly marginalised by patriarchy and caste, often suffers in silence, misdiagnosed, untreated, and unheard. These are not aberrations but systemic failures.

Policy responses must therefore abandon the fiction of universality. The language of “access for all” masks the fact that not all bodies begin from the same place. Interventions must be deeply intersectional: sensitive to histories, geographies, and social positions. It is only through such an attuned approach, one that centres the lived realities of the most marginalised, that public health can become a domain of justice, not just charity.

The Grammar of Structural Violence

What sickle cell disease reveals is not only a failure of medicine, but a failure of memory, a wilful amnesia that refuses to confront how caste structures biological vulnerability itself. The gene does not circulate in a vacuum; it is inscribed into the bodies of those consigned to ecological abandonment, medical neglect, and political invisibility. This is not heredity alone- it is the afterlife of structural domination.

To speak of health without speaking of caste is to misname the crisis. It is to treat the symptom as isolated, when it is systemic. The language of public health must cease its retreat into abstraction; the violence is not theoretical. It is geographic. It is corporeal. It is caste made flesh.

Claims to a “casteless” society function not as aspirations, but as evasions. They enable a politics that is satisfied with optics over redistribution, with tokenism over transformation. In doing so, they foreclose any reckoning with the social conditions that continue to govern who falls sick, who is diagnosed, who is treated, and who is forgotten.

Dr. Ambedkar did not demand inclusion into a poisoned system. He demanded its reconstitution. The insistence on conversion and education was never about assimilation, but rupture- an ethical refusal to accept a world that normalises suffering for some as the price of comfort for others. That remains the demand: not healing within injustice, but healing through its dismantling.

There can be no health equity in a caste society. There can be no justice without memory. And there can be no future unless the structures that made us sick are named, confronted, and dismantled, not gradually, but fundamentally.

The annihilation of caste is not an ideal. It is the only cure.

Inherited Pain: How sickle cell reveals the intergenerational violence of caste

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