If Anita Sharma*, an ASHA worker (or Accredited Social Health Activist), had a Twitter account, she could have tagged @drharshvardhan, the health minister, and introduced herself thus: My name is Anita. My job profile has changed since the coronavirus pandemic. These days I work for more than 12 hours. My meagre salary of ₹2,000 per month, which was only raised to ₹4,000 last year, has not been paid. In fact, I have not been paid at all since February.
The social media platform may have amplified her voice and drawn the attention of the movers and shakers. It might have also led to a flurry of tweets of commiseration. The outrage and publicity generated might have even raised hopes that her salary backlog would be credited into her account in one lump sum.
But that was not meant to be. Instead, Anita keeps her head low, covers her face with a mask stitched from her old clothes, washes her hands as frequently as she can (she doesn't want to run out of the only 500ml bottle of santiser given by the government), and goes about her job in Haryana with a prayer on her lips. "They expect us to do everything but don't give us even the minimum protection," says Anita.
ASHA workers have been visiting 25 homes on an average every day during the pandemic. | Photo Credit: REUTERS
Anita leaves home by 8 a.m. every day, going house to house, checking on people, specifically the children, the aged, and pregnant women. On an average day, she visits 25 homes and prepares a list that is updated every day. She could mean the difference between life and death for many people.
For every health scheme launched by the Ministry of Health and Family Welfare, it is women like Anita who step in to implement it at the grassroots level. From distributing iron tablets to checking on immunisation schedules of babies and pregnant women to carrying out periodic checks on TB patients, Anita's job has expanded now to watching out for signs of COVID-19 and counselling people. She also keeps an eye on migrant workers who have returned after their livelihoods evaporated overnight. She ensures they are observing their quarantine period in the designated centres. Besides all this, she also disseminates pandemic precaution tips to her flock.
At the forefront of India's healthcare system, which is now creaking under the weight of the pandemic, are nine lakh ASHA workers like Anita who are soldiering on — unarmed, unprotected and poorly paid. Their job is thankless.
Many of them have had to deal with hostility. "In Kozhikode, one worker's scooter was damaged when she asked a group of men to disperse during the lockdown. Some men ask why they should listen to a woman," says P.P. Prema, an ASHA worker from Kerala.
Worse, it is estimated that 20 ASHA workers nationwide have succumbed to COVID-19. Bheemakka, 51, an ASHA worker, died while on duty in Badanakatte village in Ballari district, Karnataka, on May 13. Her relatives kept the body in the hospital for an entire day, seeking insurance for the COVID-19 warrior. The doctors argued that she had died of a cardiac arrest, had tested negative, and was therefore not eligible. The local MLA and other leaders promised they would discuss her case with the Chief Minister, but are yet to respond. As this goes to print, two ASHA workers, one anganwadi worker, and one health assistant who tested positive in Karnataka have returned home after hospitalisation for COVID-19 and recovery.
Renuka Renukegoudar, an anganwadi worker from Hirebagewadi in Karnataka's Belagavi district, has also recovered only recently. She said that even though rules specify that doctors and paramedical staff have to also do the rounds in containment zones, nobody ever turns up. "Only ASHA and anganwadi workers do the difficult work of door-to-door surveys, detecting positive cases, tracing primary and secondary contacts, patrolling containment zones, and distributing food and medicines. In some villages, where neighbours were not ready to sell food or milk to former patients, I had to bring food from my house," says Renuka.
Renuka was working in a high-risk area with a cluster of 20 cases when she tested positive. When she returned home after recovery, she was boycotted by the villagers. "My neighbours stayed away from me and my daughter. Even at work, I faced stigma. A lot of us have unfounded fears about the disease. Most people want to avoid you, even if you have been cured."
Renuka has been an anganwadi worker for 19 years now, beginning with a salary of ₹800 and now earning ₹10,000 a month. Workers' unions have come out strongly against the insensitive handling of frontline health warriors. S. Varalakshmi, president of the ASHA Karyakartara Sangha in Karnataka, says: "The government maintains that Bheemakka did not die on duty. She was on duty when she collapsed. She died on the way to the hospital. How can it be treated as not dying on duty? We have demanded that all ASHA and anganwadi workers and health assistants be regularised or treated on par with other regular employees and given all benefits such as insurance."
Wherever ASHA workers are part of a strong union, they get heard. In Maharashtra, when ASHA workers were not paid from last September, they threatened to go on strike. The government promised to pay up, but it is unclear whether they will get any incentive as promised by States like Telangana and Kerala. In response to the increased workload due to the pandemic, Kerala and Telangana have hiked ASHA workers' salaries to ₹7,000 per month, while Karnataka pays ₹10,000 per month.
Uttar Pradesh, Haryana and West Bengal are other States where salaries have been delayed. An ASHA worker's salary typically works out to ₹2,000 per month from the Centre and ₹2,000 from the State governments.
Right to dignity
According to an Amnesty report, as early as April 28, the World Health Organization (WHO), had called upon all governments, employers, worker organisations and the global community to take urgent measures to protect the occupational health and safety of frontline health workers and emergency responders, respect their rights to decent working conditions, and develop national programmes for their safety.
As the pandemic spirals out of control, the responsibilities of ASHA workers have increased exponentially. According to the Health and Family Welfare's Model Micro Plan for containing local transmission of COVID-19, it was ASHA workers who were deployed early on to conduct door-to-door visits and report back on symptomatic as well as asymptomatic cases.
In Kerala's Thrissur district, where the country's first COVID-19 case was detected in January, ASHA workers like Ajitha Rajan were asked to keep tabs on the health of travellers from abroad from early February onwards. In Kozhikode, Prema, who is also Kerala president of the CITU-affiliated ASHA workers' union, says: "We are on the job all the time. We have to take late-night calls from neighbours informing us of somebody's return from outside the State; we have to comfort distressed people in quarantine."
Latha Raju has filled several notebooks chronicling the number of people in home quarantine in her ward in Kochi — where these people live, where they have travelled from, their contact details.
She also has to keep notes on any elderly people living alone, people with existing ailments and pregnant women. In the evening, these figures are sent to junior public health nurses and health inspectors, contributing to State-wide data.
ASHA workers in Kerala have also been delivering groceries, medicines, and food from community kitchens to homes.
Their responsibilities increased when lakhs of people started returning home. They became a crucial part of ward-level committees that were formed to monitor people in home quarantine. They visit the person along with ward committee members and inspect the home to see if there is an attached bathroom and home quarantine can be followed. They then brief the family on safety protocols.
Disturbingly, ASHA workers in many States have not been provided with PPE — masks, gloves or face shields. Many of them have to make do with cloth masks made at home or dupattas wrapped around their faces. After positive cases were detected among them in Kerala's Thiruvananthapuram, Pathanamthitta, Malappuram and Kollam districts, the women have turned wary. "If one of us tests positive, the contact tracing process would be frightening," says Latha. The indifference to their well-being is inexplicable, given that the country's COVID-19 fight is buttressed by ASHA workers and their rapport with people.
In a recent article (published in The Hindu) M.S. Seshadri and T. Jacob John wrote that the most important step in the coming days "would be to educate rural people with all the tools at our disposal. We need to give them accurate information." One can't imagine anyone but these unsung workers being able to do this.
Meanwhile, the exhaustion of maintaining a strict vigil is setting in as the numbers of infected cases increase. But, as Prema says, "The smallest lapse could undo months of good work." So they soldier on.
(* Some names have been changed to protect privacy.)
With inputs from Rishikesh Bahadur Desai and Abhinaya Harigovind.
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