Introduction to Kerala
Kerala stands out among the states of India, not only for its relative poverty, but for the truly remarkable array of basic health benefits which it manages to provide to its citizens. Despite having a per-capita GNP of only $298 in 1991, Kerala boasted a nearly one hundred percent literacy rate, and had one of the lowest incidences of child malnutrition in all of India. By contrast, the GNP in the rest of the country was $330, and the adult literacy rate only 52% (Franke and Chasin 1994). The robustness of health of Kerala’s citizens also shows through in a variety of other metrics, and the extraordinary success of Kerala’s ambitious program to settle entrenched historical inequities and promote truly exceptional widespread health demands an explanation. In fact, the phenomenon of the state’s development has been so well studied that the “Kerala Model” is frequently referred to by economists, anthropologists, and policy-makers alike.
However, looking simply at the health metrics in Kerala is not sufficient. To fully understand its current situation, one must take a biosocial approach. This means recognizing that “measurable biological and clinical processes are inflected by society, political economy, belief, desire, to a similar extent as other aspects of social life” (Farmer, et al). For Kerala, this entails looking not just at the failures or successes of currently implemented policy, but also at the historical circumstances which informed it and the social structures which surround and shape it. Only by looking at the Kerala model more deeply, analyzing it through a variety of disciplines, can we hope to find meaningful answers about the causes of its successes and failures, and its applicability and meaning in a broader world context.
One aspect that contributes to the uniqueness of Kerala is the strong civil activity and organization of its citizens. This history of mobilization started centuries ago under the oppressive and demeaning caste system, pressing vital reforms through entrenched local and national interests to result in the current notable health statistics. Though the benefits of these reforms are experienced both biologically and socially, they come as the result of deliberate moves of policy and advocacy which organized the disadvantaged to fight for their own rights. With that opportunity, the people of Kerala have managed to structure and enforce specific reforms which have direct, beneficial effects on the way they live.
Kerala is often dismissed as a special case, a perfect storm of ecological, historical, and individual circumstances. However, the characteristics of Kerala which enabled its success are not strictly limited by setting, and the approach it took toward advocacy, policy, and reform can apply in broader contexts, and has. The idea of education as mobilization addresses one of the main problems in development today – the fact that that it often enhances inequality even as it promotes GNP-level growth – by working to combat “structural violence” at its roots (Farmer). Kerala challenges the assumption that countries have to experience economic growth on the national level to be lifted out of poverty by showing that meaningful education reform and the nurturing of an engaged active citizenry can create a better standard of life without succeeding on any traditional monetary growth metrics. The state’s uniqueness is not then a testament to the Kerala Model’s ineffectiveness or irreplicability, as some allege, but to the deep entrenchment of the economic growth model and the interests which support it.
History of Kerala
Kerala’s successes are the result of a long history of division and struggle. Up through the 1900s, people in that area were bound by a rigidly inflexible caste system. Subtleties of dress and speech “ensured that a person’s place in society could be recognized at a glance” (Jeffrey 1992). These highly visible classifications in turn determined how wealth was distributed and how different social groups interacted. Higher-caste groups were considered pure; they owned the land or were priests, while lower castes were relegated to the most menial labor and considered contaminated or polluted. Though this system was in place throughout India, it was both particularly elaborate and exceedingly strict in Kerala. In the nineteenth century, Indian reformer Swami Vivekananda called the region “a madhouse of caste” (Franke and Chasin 1994). Chief among the restrictions imposed on the lowest castes were their inability to own land, interact with higher-caste individuals, or enter Hindu temples, but other instances of structural violence against lower-caste Keralites were innumerable and utterly pervasive. These inequalities were doubly entrenched in tradition and religion in India, making them especially intractable. However, as described later, education for critical consciousness works to counteract the systemized violence of the caste hierarchy by teaching people to question the system rather than just adapt to it.
The caste system epitomizes traditional authority, which social theorist Max Weber described as “resting on an established belief in the sanctity of immemorial traditions and the legitimacy of the status of those exercising authority under them” (1964). Traditional authority differs from bureaucratic, or rational-legal authority in that it is historically derived. Because of this, policies are determined by custom, or the whims of whoever custom selects to rule. The utter lack of meritocracy in such a static caste society meant that edicts from the ruling class could only be enforced as long as the tradition on which they were grounded continued to prevail. As challenges to the traditional system came in the form of the caste liberation movement, they also inspired challenges against the idea of top-down authority at all. When the caste system finally fell, those who had been most disadvantaged by it had also learned that social and governmental structures were not infallible – that they could be agitated against.
Education played an important part in Kerala’s tremendous transition from a rigidly caste-divided society into one of India’s most egalitarian states. Though the region historically had strong literacy rates, it was the early-1900s expansion of the education system into the countryside which paved the way for the mass mobilization and active citizenry which today define Kerala. However, this early emphasis on vernacular schools (schools which taught in the native language, Malayalam) was actually implemented with much the opposite intention. A Maharaja of Travancore explained the pro-education policies by saying, “a government which has to deal with an educated population is by far stronger than one which has to control ignorant and disorderly masses. Hence education is a twice-blessed thing – it benefits those who give it and those who receive it” (Jeffrey 1992). Though advocating for education, he and other elites believed it would lead to a less barbarous, easier to control populace. In this case, limited knowledge about the effects of literacy and education, led decision-makers to implement policies with results almost diametrically opposite of what they intended, a phenomenon Robert Merton called “the unanticipated consequences of purposive social action” (1936). Ironically, the very education reforms structured to make the populace easier to govern would help inform the radical movements which later swept Kerala. This gap between expectations and results shows most clearly in the selection of Booker T. Washington’s Up from Slavery as a required text. While educational authorities applauded “Washington’s emphasis on deference and slow, peaceful change,” low-caste Hindus read it as a manual for how to go about challenging their oppressive situation. In this case, the maharajas were simply unable to fully understand the impact that the texts they selected would make, and because of this they never anticipated the revolutionary seeds their own purportedly placating school system would sow.
The school system in Kerala directly challenged the traditions of the past. It mixed the castes, even as it heightened awareness of ethnic identities by using them for scholarship distribution and other such organizational purposes. These hardened social identities challenged traditional modes of hierarchy and deference in Kerala, giving rise to a much larger movement. Schools became a testing ground for little acts of rebellion, and as Gandhi’s nationalist non-cooperation movement swept the country, it found many student followers. Rebellion was literally taught in class – teachers were paid little and irregularly, and they objected, noisily. “From the mid-1930s, vigorous teachers’ unions spread new ideas and forms of protest into distant corners” (Jeffrey 1992). This idea of dissent, of critically examining one’s situation and working to change it, strikes at the heart of structural violence, which perpetuates its injustice by being unnoticed. For this reason, the very first movements of the educationally engaged Kerala citizens were to combat these systemic injustices, mostly through land reforms.
The various modes of dissent against structural violence became part of the social landscape of Kerala, incorporated through years of organized activism like temple entry marches, which sought to gain access to segregated temples, and “interdining,” which publically broke taboos by showing high- and low-caste Indians eating together (Franke and Chasin 1994). As the former students became teachers, this method of mass organization as communication became an integral part of Kerala’s culture, a process which Berger and Luckman refer to as “the social construction of reality” (1967). However, while Berger and Luckman tend to use the term to describe the institutionalization of authoritative social realities as seemingly objective and binding laws, it means something rather different here. It still refers to the process by which a socially-constructed understanding becomes an opaque, concrete reality of life, but in Kerala that fact of life is not a monolithic structure, but a movement of people. The reality which has been socially constructed through years of protest is that of an organized populace, effective at representing their viewpoints. Literacy is widespread in Kerala, information-seeking and active citizenry encouraged, protest expected. Though these are all social facts, constructed by the activism of Kerala’s people, they also became objectified over time as a concrete reality, influencing policy and lives by the ever-present threat of mass mobilization.
In fact, it was this reality of this active peasantry that allowed for the passage of many of the most revolutionary reforms in Kerala. Education itself, though originally instituted by benevolently misguided maharajas, relied on the activism of the lower castes as well. They instituted reading and writing circles, which had a strong Marxist component and ensured that “the right to literacy in Kerala was transformed from a purely government-sponsored policy to a popular mass movement” (Franke and Chasin 1994). These sorts of grassroots movements, such as the 1990 Total Literacy Programme, helped Kerala to achieve 100% literacy by 1991, while the overall literacy of India was just 52% (Franke and Chasin 1994). However, key to understanding the literacy movement is an emphasis on what was being taught, that people were learning to think critically about themselves and their situations. This in turn led to a more active and engaged citizenry which was better able to protect its own interests throughout various forms of government. Paulo Freire described the prerequisite for participating in meaningful social change as “a form of education enabling the people to reflect on themselves, their responsibilities, and their role in the new cultural climate,” and though he wrote about Brazil, his words are equally resonant when trying to describe what distinguishes the political consciousness of Kerala (2008). Though education began the reform movements in Kerala, those movements soon became the basis for education through the efforts of a class that prioritized and fought for empowering Keralites through meaningful, thought-provoking literacy campaigns.
However, education was not the people of Kerala’s only priority, nor even their first. Access to land had also been historically highly restricted, and as the class consciousness of the peasants grew, they found the traditional system of tenancy increasingly exploitative and insufferable. Radical associations began as early as 1915, when activists formed the Malabar Tenancy Association, and they continued to gain steam all the way through 1957, when Kerala elected a Communist Party of India majority to the state legislature (Franke and Chasin 1994). The first priority of this administration was to implement significant land reform, which they did on November 9, 1957, through the announcement of the Kerala Agrarian Relations Bill (KARB). Immediately, the bill faced strong opposition from the landed interests, including a member of the Praja Socialist Party, a misleadingly-named organization which had in fact often been called “the party of the past” in India (Fickett 1973). In the debate, a prominent PSP member named Joseph Chazhikkadan “compared the KARB to Pandora’s Box, the revenue minister in charge of the Bill to Pandora, and the provisions of the Bill to leprosy, tuberculosis, rabies, a scorpion, snake, wolf, and so on” (Radhakrishnan 1989). In the face of this virulent opposition, however, there was widespread peasant mobilization to support the bill. Throughout the debate, radical groups mustered support for the KARB, including rallies, conferences, meetings, and other demonstrations. When the central government of India launched a joint steering committee to remove the elected radicals with “the declared aim of saving the state from communist attacks and establishing peace, democracy, and democratic government,” supporters of the communist ministry took to the streets for 50 days, picketing government institutions and schools (Radhakrishnan 1989). Though Kerala’s communist government was indeed dismissed by the ruling Congress party in India at the end of that period, the replacement ministry still had to deal with these activists. Despite a variety of adjustments made which eliminated many of the protections for tenants, the revised legislation passed in 1960 as the Kerala Agrarian Relations Act retained most of the provisions of the KARB, and still “provided major economic relief to tenants” (Franke and Chasin 1994). However, subsequent protests by wealthy landowners and appeals to the central government succeeded in substantially watering down the already diluted KARA.
Legislative disappointments aside, radicals in Kerala certainly gained more from the brief communist ministry than they lost. In addition to the precedent set by the passage of a substantial land reform act, there were also benefits which, though less immediately tangible would have even greater ramifications for the future. By the time the seven party United Front, led by the Communist Party of India – Marxist, was elected to power in 1967, many of the most substantial impediments to land reform had been removed. This revival of the leftists’ prior agenda was enabled by a variety of factors, such as the breakup of the anti-communist alliance which previously thwarted the KARB, the splintering and dissolution of the Congress party, and the increased mobilization of the peasantry which had resulted from the alliance of formerly anti-communist groups with the left to work for mass interests. Though the passage of the Kerala Land Reforms (Amendment) Act in 1969 was itself relatively uneventful, – by this point, popular pressure had driven most political leaders to support the bill – the KLRAA still had a massive impact on the division of resources in society, turning 1.5 million tenants in small land owners. However, it is important to emphasize that this reform was not just the result of a quiet vote or secluded legislative debate. “Quite the contrary, it was the outcome of decades of organizing, petition signing, marching, meetings, strikes, battles with police and landlord goon squads, election campaigns, and parliamentary debates” (Franke and Chasin 1994). Importantly, all this mobilization was initiated by a critically educated citizenry which was prepared to fight for its convictions.
Kerala’s transition in the early twentieth century from a rigid, caste-defined society to the implementer, in large part by a mobilized peasantry, of one of the most thorough land reforms in South Asia depended ultimately on early efforts to educate the entirety of its citizenry. Though that educational movement was started with much the opposite intention, the skills and material taught enabled everyone in Kerala to look critically at their situation and to fight for improvements, in both education system itself and in the exploitative distribution of property and the outmoded laws which protected established interests. Key to understanding the increased mobilization of popular resources was the institutionalization of radicalism as a mode of learning and of protest in Kerala. Through successes like the land reform acts, the great mass of the previously disadvantaged came to understand themselves as having a role in crafting of the policies which affect them, and over time this understanding solidified itself as a society in which even the most wealthy and elite were forced to reconcile their aims with those of the least privileged.
Health Outcomes in Kerala
Tracing the history of Kerala shows how the disenfranchised took back crucial elements of their own governance through education and mobilization. However, the effects of that newfound government remain to be demonstrated. Though Kerala did not experience the economic boom that is often conceived as marking development in poor countries, the various metrics of quality of life have improved significantly, a phenomenon Srikumar Chattopadhyay and Richard Franke referred to as “accomplishing more with less” (Freund 2009). On its most basic level, this can be shown as a comparison between Gross National Product and life expectancy. Under traditional understandings of development, an increased GNP corresponds with more wealth and a higher individual standard of living. However, Kerala is an exception to this rule. Despite having a per capita GNP of only $298 in 1991, as compared to India’s overall GNP of $330, Kerala had an average life expectancy of between 69 and 72 years. India’s average life expectancy was 60 years, and the life expectancy of other countries as economically destitute as Kerala was only 55 years. In fact, Kerala’s life expectancy was only 4 to 7 years shorter than that of the United States of America, despite the latter having an approximately 75 times greater per capita GNP (Franke and Chasin, 1994). Clearly, the state is outperforming classical expectations of development based on economic growth.
However, simply comparing GNP and life expectancy does not tell the whole story of a population’s health. Fortunately for Kerala, nearly all the other metrics are equally favorable.
By the end of 1991, Kerala had achieved 100% literacy, while the rest of India lagged behind at only 52 percent. In keeping with Kerala’s tradition of citizen-led movements, the 1989 Total Literacy Campaign which enabled Kerala to reach this goal was run in large part by the Kerala People’s Science Movement, a 70,000 member volunteer organization (Franke and Chasin 1994). Though literacy had regressed in Kerala by 1994, it retained the unique characteristic of being relatively equitably distributed between men and women. While the male literacy rate was 93.6%, female literacy was still 86.3%, which was 35 points higher than general literacy in the rest of the country. In contrast to this seven point literacy gap in Kerala, the difference across India was 25 percentage points – male literacy was 64%, and female literacy only 39% (Parayil 2000). Additionally, there is evidence that literacy in Kerala is not just learned as routine, but is put to active use. Despite their poverty, Kerala’s citizens have the highest newspaper consumption in all of India, supporting the assertion that “literacy in a progressive and mobilized political environment also enhances political awareness” (Franke and Chasin 1994). Kerala’s remarkable literacy rates are certainly an achievement in and of themselves; they speak to a remarkably far-reaching and engaging educational system. Even more important, however, is the fact that literacy in Kerala has a greater connotation, that it signals a well-informed populace, able to participate actively as citizens.
Literacy is only one metric of development, and it speaks little to the physical health of the population. However, it is not the only improvement in the lives of impoverished Keralites which was implemented by the radical regimes of the 1950s and 60s. In a 1981 census which measured the percentage of villages which had access to specific vital resources, Kerala ranked first among Indian states in nearly every category, ranging from schools, to food ration shops, to post offices and hospitals. A similar survey found that while India as a whole had only 263 hospital beds per 100,000 people living in urban areas, Kerala had nearly twice that, at 458. The difference was even more marked in rural areas, where for 100,000 people India averaged 12 beds and Kerala averaged 107, despite being significantly poorer (Franke and Chasin 1994). Though the region was still extremely impoverished, even compared to other Indian states, the resources which it did have were distributed more equitably, resulting in a higher basic standard of living and better access to healthcare.
This speaks to the prevalence of the institutions of care, but a still more biological analysis of population health is also necessary. In addition to Kerala’s high life expectancy, it also had by 1991 an infant mortality rate of 17 per 1,000 live births, as opposed to the all-India rate of 85. Infant mortality per thousand in comparably low-income countries was 91, while in the USA it was 9 (Franke and Chasin 1994). Whereas between 1990 and 1996, only 34% of births in India were attended by trained health personnel, in Kerala 94% of births were attended, a fact which no doubt contributes to Kerala’s relatively low infant mortality (Parayil 2000). Kerala also has a relatively low birth rate; at 20 per 1,000, it’s much closer to the USA’s 16 than India’s 31 or other low-income countries’ 38 (Franke and Chasin 1994). These indicators – high life expectancy, low infant mortality, and low birth rate – all correspond with increased access to effective medical care, which is especially remarkable given the overall dearth of wealth in Kerala. These strong health metrics epitomize the central paradox of Kerala, that of accomplishing more with less.
However, the area of public health in which that trope of accomplishing more with less shows through most strongly is nutrition. Since the Indian food shortages of 1964, Kerala has used ration shops to provide nutrition for the most destitute. As a result of rationing and similar food provision programs, like free school and nursery lunches “nutrition in Kerala is equal or superior to that of other parts of India” (Franke and Chasin 1994). It is certainly true that Kerala suffers from less widespread malnutrition than the rest of India. Between 1988 and 1990, the percentage of children in Kerala who suffered from severe undernourishment was only 1.6% or 2.4% for boy and girls respectively, compared to the all-India rate of 9% (Parayil 2000). However, it is likely that this is not actually the result of a significantly increased per capita caloric intake (Indians averaged about 2100 calories per day in the early 80s, while estimates for Kerla ranged from 1600-2300), but rather from a mode of distribution which assures even the most indigent of their basic requirements, as well as from better access to primary healthcare centers, which can treat the effects of improper nutrition if necessary. The public food distribution system in Kerala is widely considered the most effective in the state, and 90% of individuals hold ration cards (Ramachandran 2000). However, it is important to note that these food reforms were not simply handed down from the administration, rather “it was primarily the outcome of decades of struggle by workers and tenant farmers to control the landlords and other elite forces exploiting them” (Franke and Chasin 1994). In this way, Kerala’s history of mass movements plays out on even the smallest scale, the individual bodies of its citizens.
The mobilization of Kerala’s citizens does not just change policy; it affects their health on the level of both a single individual and the entire population. The ability to effectively represent their own needs, enabled by a critical education, allowed the people of Kerala to pass redistributive reforms, in particular regarding land, food, and education, which in turn have a direct beneficial effect on their health as measured by any number of indicators. There are problems with this radical approach. One of the most common critiques is that the sort of social safety net in place in Kerala creates a welfare state, where people have no real motivation to work. And at first glance, troubling economic statistics like Kerala’s 25% unemployment rate seem to support this view. However, unemployment is a much deeper historical problem in Kerala; it existed long before the communist ministries. Additionally the unemployment crisis in Kerala is most severe in agriculture, where male laborers averaged only 147 working days per year in 1983-84 (Franke and Chasin 1994). Both these factors ought to be taken into account when looking for the cause of Kerala’s unemployment.
Because unemployment is a historic trend in Kerala, its cause must also be historic. The most likely candidate is Kerala’s extremely high population density; at 786 people per square kilometer, it is nearly three times that of the rest of India (Parayil 2000). This explains both the longstanding nature of Kerala’s underemployment and the fact that there are simply too many people to work the land every day. As more underlying causes of unemployment are fleshed out, the welfare state argument loses traction, and it becomes clear that the effect of the redistributive reforms in Kerala is not to discourage work, but to create a backup system for those who cannot find it. These reforms were designed and militantly put in place by the advocacy of the least advantaged members of society, in order to protect their most basic needs, like land and food. The citizens in question are both unreservedly motivated and extremely effective because of their high level of education, and their advocacy leads to a state with a standard of living much more advanced than its economic growth metrics suggest is possible.
Kerala in a Broader Context
Kerala is a large state, but it is still only a tiny fraction of a much larger developing world. However, its role as an alternative model of development makes Kerala of huge importance in the question of whether a similarly radical set of reforms would have the same effect in other places. The argument put forth in Franke and Chasin’s book is that the success of Kerala was locally defined, enabled by the specific conditions of Kerala’s ecology, history, and people’s movements (1994). However, to say that the specificity of the conditions which preceded Kerala’s transformation preclude similar reforms in other regions is disingenuous. Though Kerala’s evenly dispersed resources (and therefore evenly dispersed population) may have made it easier to develop a comprehensive education system, the prevalence of similarly literate societies in regions as dissimilar as Azerbaijan, Cuba, and Equatorial Guinea makes shows that this primary goal of universal education can be accomplished in diverse settings if prioritized (UN Statistics Division 2011). From this understanding, the emphasis placed on the specific people and history of Kerala can be reexamined as just part of the impact of early educational reforms. Through education, the citizens of Kerala were able to bring about for themselves the reforms they needed most, and though there are certainly extraordinary challenges associated with instituting full literacy to the point of critical consciousness, they are not categorically prohibitive in the rest of the developing world. Nor are the beneficial effects of early education only evident in that particular state – a 1991 study with compared the differences in development between four Scandinavian countries and four comparably-sized Latin American ones identified the two critical components of the relative advancement of the Scandinavian countries as education and early land reform, a trend supported centuries later and half a world away in Kerala (Thorp 1993). Kerala, though a current and compelling model, is not the only evidence that a policy of radical reform and redistribution, informed by the advocacy of the people most affected, produces significantly better health and development outcomes than pursuing a never-ending policy of economic growth.
Why then, does the trope of economic growth as the premiere mode for human development persist? Despite being outmoded and possibly even counterproductive, that particular holdover from colonial ideology retains its power in the same way that the caste system endured for so long – by being a traditional authority, institutionalized over centuries. Throughout the colonial ages, it was simply the goal to get more, to grow straight through the edges of the map. Over time, this idea of expansion as the only possible method of development solidified and the colonial process which brought it into being became opaque. It existed as its own reality, a law of development. Kerala (and increasingly more and more research on similar phenomena) challenges this traditional understanding that development means economic growth because this growth comes at the expense of increased inequality and often does nothing to advance the interests of the vast majority of society. It shows that traditional models of growth fail to take into account the potential of a consciously educated and mobilized population, that such populations can and have instituted radical reforms policies through mass advocacy which end up drastically raising the quality of life for all citizens.
The problem which Kerala highlights in global health, is the persistence of traditional modes of examining development, of building more more instead of accomplishing more with less. The solution is then being willing to use seemingly radical techniques and reforms to accomplish development on a human scale, as opposed to on the economic scale it is measured on now. Put simply, it is the difference between raising life expectancy and raising GNP. However, the implementation of these reforms cannot be put equally simply, for the fundamental reason that the radical changes in society have to come from the advocacy of the population which they purport to affect. As such, education, not just for routine literacy, but for critical consciousness, is a vital first step. It teaches citizens to integrate meaningfully with the world around them, to define it rather than just adapt to it (Freire 2008). The definitions of how to achieve human health and developmental success which countries struggling to survive in the Darwinian world of global economic development could come to are unknown, but Kerala shows that critically examining one’s context and making, by mass protest if necessary, the appropriate adjustments leads to a radically more healthy, egalitarian, and meaningfully informed society.
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