These workers are on the frontlines, reporting symptomatic patients, tracking those in quarantine and from abroad, and conducting contact tracing.
Last week, a group of seven accredited social health activists, or ASHAs, were asked to visit 300 houses in Bengaluru’s Gauripada. The Bengaluru corporation’s health department instructed them to “impart information” on Covid-19 after a person in the area showed symptoms of the virus and was sent to a hospital to be tested.
Nagalaxmi V, 43, was one of the ASHAs deputed for this purpose. They had received no specific training on how to go about it, she said, and relied on pamphlets handed to them by the health department. To compound their problems, the people whose doors they knocked on were angry.
“The people in the area were shouting at us: ‘Why have you come? You do not even have a doctor with you.’ Our superintendent asked us to shoot a video. We told her that they are not even letting us talk, let alone shoot a video,” Nagalaxmi said.
She added: “At the time, we were only wearing masks we brought. You can imagine how scared we were. What if there was someone positive for coronavirus in the area? Don't we have a life, don't we have a home, don't we have children?”
Nagalaxmi has three children. Her husband works as a contract worker with the Bengaluru municipality.
ASHAs have been an integral part of the Indian public health system for more than 10 years. By imparting health education and spreading awareness on government schemes, these community health workers are involved in every single public health programme in the country. This includes registering women for antenatal check-ups, vaccination of children, doing surveillance for TB control, and conducting tests for the diagnosis of malaria. Their role has been well documented as being successful in improving access to maternal health facilities, and reducing malaria.
Their work is voluntary, receiving a meagre honorarium ranging from Rs 2,000 to Rs 10,000. They also get incentives, which are dependent on the jobs they do in a month. Most ASHAs do not receive their payments on time. In January, ASHAs in Karnataka went on a strike after being unpaid for 15 months.
And with Covid-19, they are in uncharted waters.
Newslaundry spoke to ASHAs in Bihar, Karnataka and Haryana to understand the situation.
Most of the workers were not trained to understand the virus’s symptoms, prevention or control. Many of them haven’t been provided with personal protection equipment like masks, sanitiser and gloves; some workers received equipment only after repeated demands made through their unions.
According to the government’s Model Micro plan for Containment of Local Transmission, an ASHA should be deployed to interact with the community, report symptomatic cases, conduct contact tracing, monitor people under quarantine, and provide information on preventive public health measures. ASHAs have been asked to cover a range of 20-25 houses in rural areas to 60 houses in urban areas.
“In this case, we are not even keeping a record of how many houses we visited,” said Nagalaxmi. “This job will be completely unaccounted for.”
‘We are working even if we are scared’
In Bihar’s Araria district, migrant workers are returning from other states. Kiran Jha, who is around 50 years old, is an ASHA facilitator and is finding it tough to motivate ASHAs working under her to go out on the field. The ASHAs haven’t been given any protective gear, and are worried about contracting the virus.
“We have been told that if someone is infected, it can spread up to a radius of six kms,” Kiran said. “I told my ASHAs that if they are going to die anyway, why die locked up in the house? Let us go on the field and work. Kaam karke marengo, apna dharam nibhate (We will die while we do our duty).”
ASHAs across states have been asked to identify symptomatic migrant workers, who will later be tested by doctors and nurses. ASHAs will then have to track them for 28 days, Kiran said.
The doctors’ teams have masks and cars, but the ASHAs themselves have no protection. With public transport suspended, they walk up to 10 km sometimes to search for migrant workers in the area.
Kiran said that migrant workers heading back to their villages are scared. “They are scared that the police will take them away, that they will be made unconscious and kill them,” she said. The ASHAs also have to assuage these fears, and tell them they will be taken for medical treatment or will be quarantined.
Last week, Kiran had a hard time testing a pregnant woman who had returned from Delhi. “Her room was very dark and we could not see anything. We went inside and spoke to her. The woman said, ‘I will die but not check myself.’ I told her family members to isolate her, which scared the woman. She finally came out and got tested by the doctor’s team,” Kiran said.
Like Nagalaxmi, Kiran and the other ASHAs she knows face abuse from villagers. “One ASHA called me last week. There was a patient who was identified as a migrant. The ASHA and the village chief accompanied the doctor’s team. But after the team and village chief went, the family went after the ASHA.” The ASHA was allegedly abused for reporting the migrant worker to the health system.
The village chief should have intervened in such a situation, Kiran said. “The family told her: ‘Why did you give my son’s name to the medical team? If something happens to my son, we will file a case against you?’ We all live in the same community. While we are working for them, they feel we are endangering them.”
In Bihar, ASHAs have not received any honorarium so far, and have only been receiving sporadic incentive payments.
Without training, workers rely on smartphones
In Haryana, ASHAs have been asked to track those who have returned from foreign countries, ensure they are quarantined, and see that they follow social distancing norms like staying isolated and washing hands.
But the ASHAs are struggling without training. Sunita, 39, an ASHA in rural Sonipat, Haryana, refers to the government’s automated caller tune, a Covid-19 advisory. “We haven’t been trained on even what is being said in that message,” she said. “A few weeks ago, they cancelled all the meetings related to coronavirus training saying that we should not have gatherings.”
Last month, the Ministry of Health and Family Welfare released guidelines for training front-line health workers, particularly targeted towards ASHAs. Yet ASHAs told Newslaundry they get most of their information from posters or their smartphones. Sunita, for example, has been writing out tips and suggestions for her colleagues, after asking a doctor for information on Covid-19 and its symptoms. “I also sent a photo of a poster to an ASHA in Bhiwani, so she can get some information,” she explained.
Sulakshana Nandi, a health rights activist from Jan Swasthya Abhiyaan in Chhattisgarh, said it’s unacceptable that ASHAs have been sent to work in the community without training. “An ASHA needs to know what she may have to deal with in the village. She needs complete information about it. It reflects the randomness of the state strategy related to Covid-19 control,” Sulakshana said.
In the villages, this lack of information and lack of equipment is impacting the credibility of the ASHAs.
“People are not even ready to listen to us. The people expect the ASHA to give them some mask, or medicine or sanitiser,” said Sunita. “But we ourselves don’t have these things.”
Anju Verma, an ASHA who works at a village near Ambala, said she was instructed to teach a man who had returned from abroad how to wash his hands. Anju was told to take a video recording too.
“I had to enter his house and wash my hands and take a video,” Anju said. "All this when I do not even have training. I’ve seen videos [of healthcare workers] from China where they enter houses fully wrapped in hazmat suits. We don’t even have anything to cover our faces.”
According to several ASHAs, many of the people returning home from foreign countries are from higher socioeconomic groups, while the workers themselves are from marginalised communities. This makes it difficult for ASHAs to communicate with them.
For example, Sunita had to help out another ASHA last week, who was unable to convince a family to stay quarantined in their house. The family had returned from Germany on March 11.
“They kept telling us they had already been tested in the airport. They felt they are more educated [than us] and have more money,” Sunita said. “They thought, ‘These ASHAs are villagers. What do they know?’”
The argument continued till 11 pm, until Sunita got a doctor to intervene and speak to the family. The issue was finally resolved.
Vulnerable on the roads
Not only do ASHAs fear contracting the virus, they also worry about working on the streets that are now heavily policed, thanks to the nationwide lockdown. They walk to work, covering between three and nine kilometres a day.
In Ambala district, Anju often spends entire days on her feet, trying to find people who returned from foreign countries. The addresses and phone numbers she’s provided are often wrong.
“I have spent entire days looking for one person. I have developed welts on my feet,” she said.
The work done by ASHA is informal and considered voluntary by the government. Most ASHAs do not have identity cards, which makes them vulnerable.
In Guana city of Haryana’s Sonipat district, two ASHAs were on their way to a primary health centre when they were stopped by the police. They were lathi-charged when they couldn’t show their identity cards. This video, shot by a local media organisation, clearly shows the women wearing their pink ASHA uniforms.
“The police asked me for an identity card, but we did not have one,” said Meena, who suffered injuries on her legs and hands. “Even though we were walking away, the police chased us and beat us. I was so scared, I just ran home.”
In Bengaluru’s Sadiq Nagar, an ASHA was assaulted and heckled by 50 people while on duty. Her phone was snatched and her papers were torn when she came to do a survey in the area after a domestic worker tested positive. According to Nagalaxmi, the woman is a union leader, and the incident has frightened other ASHA workers in Bengaluru.
“We have no protection. The community needs to be given the right information before an ASHA goes there. Nobody from the health department asked about us. Do they think we are working because we have nothing else to do?” Nagalaxmi asked.
What about other sick people?
A major part of an ASHA’s work is to look after pregnant and lactating women, vaccinate children, and refer sick people to hospitals.
“We have to weigh children till they are 42 days old. The first 10 days of a child’s life is very important. We check the child’s hearing, we measure his head, we check if the umbilical cord has healed,” said Sunita.
But since the Covid-19 outbreak, mothers are closing their doors to ASHAs. “They tell me not to come to our house. They say, ‘You roam around the villages without a mask even. What if our child falls sick?’ This happens especially in houses where boys are born,” said Sunita.
Several ASHAs told Newslaundry that they have been getting calls asking when their children can be vaccinated. At the moment, vaccination has been stalled in many states. This goes against WHO guidelines which said that the disruption of immunisation, even for brief periods, can increase the likelihood of an outbreak of vaccine-preventable diseases such as measles.
With most outpatient departments closed to the public, ASHAs worry about the sick people in the community who need care and treatment. Some complained that their public health centres do not have doctors, which makes it hard for them to even ask for information or refer a suspected case of Covid-19.
In Bengaluru, Nagalaxmi was worried about a 26-year-old woman who gave birth about three weeks ago and is anaemic. “Her haemoglobin levels are just 8 gms (the normal range is 12 gms/decilitre). I told the doctors in the hospital I report to about her case. They said I should advise her to eat foods such as beetroot and carrot to increase the blood in her body. During this curfew, where will she find this food?”
In Anju’s village, there is an old man whom she suspects has tuberculosis — though he hasn’t been officially diagnosed yet. He was having trouble breathing, and had a cough and cold. A private doctor said he could have TB and asked them to do an X-ray. Where can the family get these tests done now? The daughter asked me, ‘What if my father dies now?’”
Sunita said their credibility crumbles when they ask people if they have Covid-19 symptoms, but then can’t provide them relief. “Naturally they get upset. I represent the department, and I cannot tell them to go to the private sector. That too at this time, when people are dying of hunger. What do I tell them?”
For the past few years, ASHAs have been going on strike demanding more pay, better working conditions, and formalisation of their jobs. But the care work provided by these women is downplayed by the government, said AR Sindhu of the All India Federation of Anganwadi Workers and Helpers.
“This work is considered voluntary work, as if they do it for their leisure. This is institutionalised unpaid care work,” said Sindhu.
The government's apathy has increased the discontentment among ASHAs. “Abhi to hadd ho gayi. This is the limit,” said Sunita, who has not received her monthly honorarium for nearly five months. “We are working in the field without a mask or sanitiser. What kind of mindset is this?”
Most ASHAs continue working because of their emotional attachment to their communities.
M Geeta, 34, who works as a ASHA in a village near Bellary, Karnataka, said, “People at home and others have told me not to go to work if the government does not give masks. But I am attached to my village. I do not want the entire village to be infected with this virus. I will do my work happily if they had given us protection.”
The lack of regular pay is now weighing heavily as many of their partners are out of work. Geeta’s husband, who works as an auto-driver, cannot work during the lockdown. “My salary is not good enough to take care of the expenses with two children,” said Geeta.
The stress and risk of her work takes its toll at home too. “My family members tell me that nobody takes such a big headache of a job for such a small salary. Your phone never stops. Your work never ends,” said Sunita.
On March 26, Finance Minister Nirmala Sitharaman announced Rs 50 lakh health insurance and accident cover for health workers. But ASHAs are unimpressed.
“What do we do with the insurance?” asked Anju. “In some of our sisters’ homes chulha has not been lit, roti has not been made. Some ASHAs are widows who run their houses on this salary. Why give a person money after they die if you cannot give it to her when she is alive?”