India’s Women Frontline Community Health Care Workers Tracing COVID-19 Are Left Defenseless

Pune, India — After spending two weeks at a government COVID-19 care facility in Kolhapur — in the western Indian state of Maharashtra — Ashwini Patil, 35, had made a full recovery and was discharged on May 1. Early the next morning, she was back going door to door in her village in Pune, to Kolhapur’s north, tracing suspected COVID-19 patients by checking their oxygen levels and temperatures. She would distribute medicines like paracetamol and vitamin C to those who had mild symptoms.

Wearing a fabric mask and pink sari — the uniform for accredited social health activists (ASHAs), an all-women health care workforce that acts as the interface between communities and the public health system in India — the mother of three said that she didn’t have any other personal protective equipment (PPE) while she was accompanying nurses at local primary health care centers (PHCs) several weeks prior to swab the relatives of COVID-19 patients. A few days later, she developed a mild fever and cough. “Five members of my family who stay with me, including my 11-year-old daughter and grandmother, tested positive after I did,” she said.

Over the phone with me, she recounts how hard quarantine was on her emotionally. She cries recalling the two weeks she had to stay away from her two-year-old daughter, and how, after her family tested positive, her neighbors ostracized them. It was the last thing she expected, especially since she’s served them as their health care worker for over five years now.

ASHAs like Patil create awareness in their home villages around public health services, counsel people about best health practices, and help them access health services — especially women and children —with one ASHA per 1,000 people.

ASHAs typically work for a few hours, three to four days a week, while maintaining other jobs. They’re considered volunteers and given a meager honorarium of Rs 2,000 to 4,000 (US $26.66 to $53.30) per month, which doesn’t even clear the national minimum wage rates set by the central government.

Since the COVID-19 outbreak began in India in January 2020, there have been more than 28 million cases in the second-most populous country in the world. ASHAs have since been tasked with tracing patients; creating awareness about the virus and hygiene practices; addressing psychological trauma, stigma, and discrimination; and supporting PHC nurses at overburdened centers. ASHAs are also given duties at isolation centers where asymptomatic patients are treated.

Currently, 40 to 50 houses out of 400 are infected in each ASHA’s jurisdiction, according to Shweta Raj, president of Dilli ASHA Kamgar Union in Delhi.

“I go to containment zones daily,” said Patil. She said that while the government initially provided PPE in 2020, “For the last six months, they distribute it [between] gaps of a few months. I have to spend from my own pocket to buy it for my safety.”

According to an Oxfam India survey released in September 2020, 75 percent of ASHAs were given masks, 62 percent were given gloves, and only 23 percent received full bodysuits. Per the Ministry of Health and Family Welfare, ASHAs are were meant to receive to receive face shields, masks, gloves, head caps, and sanitizer; in reality, however, they’d be considered lucky to receive masks and sanitizer.

“The government does not provide PPE kits and masks regularly to ASHAs, who are frontline workers,” said Netradeepa Patil, president of the union of ASHA workers in Maharashtra. “Most of them are young, in their 20s or 30s, and belong to marginalized families, or are widows or single women. They run their families. But the government is not bothered to provide them safety.” She said that five ASHAs had died of COVID-related complications in Maharashtra, the worst affected state in India.

According to Mahesh Botle, joint director of the National Health Mission in Maharashtra — the state in which Patil works — the government has given an additional Rs 1000 to ASHAs for COVID-19 duties, as well as a life insurance cover of Rs 50 lakh (roughly $68,500) to all health workers, “including ASHAs,” she said. But their honorariums are hardly enough to cover daily transport costs, let alone a regular supply of PPE and other work-related expenses.

The second wave, which began in India in February 2021, is proving deadly, with around 350,000 cases and 3,500 deaths recorded daily in April and May; in April, the country was setting daily world records for new infections. Almost all states in India were struggling to avail beds, oxygen, ventilators, and ICU beds to COVID-19 patients. Grim reports have also come out of crematoriums and burial grounds, which are working overtime to accommodate the surge.

Consequently, said Raj, “there is no priority for ASHAs or their families in receiving treatment if they get infected.”

The government has been widely criticized for its handling of this surge. And last week, India’s highest court slammed the central government for its vaccine rollout that left states to fend for themselves and permitted private health facilities to charge people under 45 for vaccinations.

On June 3, with 1.7 million active cases and more than 337,000 deaths, India signed its first order of an unapproved COVID-19 vaccine that is still going through Phase III clinical trials. Meanwhile, the Supreme Court is demanding the government produce a roadmap for how it plans to meet its target of inoculating about 900 million adults by the end of this year.

Overworked and underpaid

Viji Prabhakaran, 35, an ASHA working and living in a rural part of the Ernakulum district of Kerala — a south Indian state — walks three to four kilometers a day to trace patients in her village, maintaining a daily register by hand of the families she checks every day, sending this data on to her seniors in PHCs. She hardly has time for her regular ASHA tasks like explaining the benefits of various government schemes to appropriate beneficiaries—pregnant women, babies, young women—for which she gets additional incentives.

“I’m asked to do duties at isolation centers where asymptomatic patients are treated. Seniors will also call me at any time of night when I’m with my family,” said Prabhakaran. “When we ask for a hike in honorarium, they tell us to leave the work.”

Meanwhile, both Patil and Prabhakaran suffer abuse by patients and their families, who accuse them of spreading the virus. “People ask us not to come to their houses,” said Patil. “They don’t cooperate at all. And they lie saying they weren’t in contact with COVID-19 patients, but, after a few days, they test positive.”

“ASHAs are the backbone of the Indian health system in this pandemic,” said Raj. “And they work 10 to 12 hours a day without fixed work shifts.” In August 2020, ASHAs went on a nationwide strike demanding higher wages, PPE, and medical insurance. Some state governments increased their pay: Maharashtra raised their wages to Rs 2,000 a month. Other states increased their pay as well, but only negligibly.

Botle admits that there are often shortages of PPE kits, but added, “As far as the honorarium hike is concerned, they are activists, not employees. And besides, only the central government can make that decision.”

The central government has yet to respond.

Now, raising public awareness about COVID-19 vaccinations, and how to register through the central government’s mobile app “CoWIN,” is left to the ASHAs.

Renu Sigh, 40, an ASHA from Uttar Pradesh—a northern state of India that is currently experiencing a surge in COVID-19 deaths—had a hard time in February and March, when the vaccination drive for Covishield (the Oxford-AstraZeneca vaccine) and Covaxin (the inactivated vaccine developed by native Bharat Biotech) began in India. “People had misconceptions, like vaccines aren’t effective or have many side effects,” she said. “We tried to answer all their misconceptions and convince them to come forward, but they wouldn’t come.”

Now that India’s facing a shortage of vaccines, however, ASHAs are being inundated with inquiries of when they would be available again. “People call non-stop or visit my home,” said Sigh. “Each center gets maybe 100 to 300 doses, which are gone within an hour. It is difficult to make them understand.”

Some are now accusing ASHAs of favoring people with political connections or influence for vaccination, which only adds more distrust toward them.

And, without support on any side, the ASHAs will remain the unsung—underappreciated, underpaid, and unprotected—heroes of India’s ailing health care system.