Photo Essay: India’s Rural Health Workers Fell Ill As Workload Spiked During Pandemic

April 19, 2022 –
From Toward Freedom

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More than 3,000 Accredited Social Health Activists (ASHAs) protested in the city of Kolhapur India's Maharashtra state on October 26 after several of their demands, such as the legal status of full-time workers, better working conditions, adequate pay, medical insurance, and others, weren’t met / credit: Sanket Jain — More than 3,000 Accredited Social Health Activists (ASHAs) protested in the city of Kolhapur India’s Maharashtra state on October 26 after several of their demands, such as the legal status of full-time workers, better working conditions, adequate pay, medical insurance, and others, weren’t met / credit: Sanket Jain

Prajakta Khade walked into a public health center daily for three months in early 2021, without ever receiving medical care. The healthcare worker’s 26 notebooks—containing more than 3,000 pages of community health records—point to why she couldn’t seek treatment for her ailments. She was simply too busy.

In March 2020, India’s health ministry tasked 1 million Accredited Social Health Activists (ASHAs) like Khade with COVID-19 duty in rural areas. This, in a country where 65 percent of its 1.38 billion people live outside cities. Suddenly, ASHAs’ workload increased exponentially. Yet, they remain underpaid and now suffer stress-related chronic ailments.

“If a positive case was found in the area, we had to visit the patient, contact trace, arrange medical facilities, measure their oxygen and temperature levels daily, and ensure they complete quarantine,” Khade explained about the added duties to treat the infectious respiratory disease. But all Khade was given to do her job in the assigned area in India’s Maharashtra state was a single N95 mask and 200 milliliters of sanitizer.

ASHAs, an all-women healthcare cadre, remain the foot soldiers of India’s rural healthcare. One worker is appointed for every 1,000 citizens under India’s 2005 National Rural Health Mission. ASHAs are responsible for more than 70 tasks, including providing first-contact healthcare, counsel regarding birth preparedness, and pre- and post-natal care. Plus, they help the population access public healthcare and ensure universal immunization, among other things.

The World Health Organization announced a pandemic in March 2020. But in many countries, lack of adequate healthcare and no social safety nets amid lockdowns wrecked the lives of ordinary people. In India, for example, an additional 150 million to 199 million people are expected to enter poverty in 2021 and 2022.

Chronic Illnesses Spike

One day about a year ago, while surveying people in her village of Vhannur in India’s Maharashtra state, 40-year-old Khade felt dizzy. But she couldn’t take a break. “At one point, my face was swollen, and I could barely see anything.” It turned out her blood pressure level had surged to 252/180 mmHg (millimeter of Mercury), much higher than the standard limit of 120/80. That is how she got diagnosed with hypertension.

However, a month’s worth of medications didn’t help because she continued to experience stress as her workload increased. Senior officials at the health center had early on issued an order to submit patient records daily by noon.

ASHAs, who aren’t considered full-time workers, receive performance-based incentives paid on the number of tasks completed. “For COVID duty, the government decided our worth as merely 33 Indian Rupees per day (43 U.S. cents),” she said. “We received this amount only for three months in the past two years.”

Moreover, during the peak of COVID-19 cases in 2021, salaries for Maharashtra’s ASHAs were delayed by five months, according to Khade. Netradipa Patil, an ASHA from Maharashtra’s Kolhapur district and leader of a union that represents more than 3,000 ASHAs, confirmed this.

One day last year, Khade’s supervisor asked for a list of hypertension and diabetes patients from her village of about 1,200 people—at 10 o’clock at night.

“How could I survey the entire community in the night?” she asked.

Often, such orders meant skipping lunch and staying hungry for 11 hours at a stretch. ASHAs worked four hours prior to the pandemic. Now, 12-hour days are normal.

When medications didn’t help, Khade consulted two private doctors. “After six months of hassle, the doctor doubled my dose to 50 milligrams.” Khade lost over 10 kilograms (22 pounds) of weight and was placed on medications to address anxiety. Even today, she suffers from fatigue.

“I was never this weak,” she asserted.

Chronic diseases among ASHAs are rising rapidly because of the workload, says Patil. “We protect the entire community, but there’s no one to look after our health.” ASHAs in Maharashtra, she says, average a monthly income of Rs 3,500 to 5,000 ($45 to $66 USD).

Indian journalism portal BehanBox mentioned the following in their March 2021 report: “The bulk of COVID tasks has impacted [the] physical health of workers. Many reported loss of weight, body pain, fluctuating blood pressure and [hemoglobin] levels. Fear of infection and debt burden has exacerbated anxiety and stress levels, adversely impacting mental health of ASHA and AWWs.” AWW stands for Anganwadi Workers (public kindergarten teachers and assistants to teachers).

When this reporter spoke to senior officials, they said they did not want to comment on ASHAs’ stress and did not want to be named. They also said senior officials are not responsible for ASHAs’ deteriorating mental and physical health, and pointed this reporter to the Indian government’s order to submit data. The National Rural Health Mission has not responded to this reporter’s questions for years. Other senior officials didn’t want to comment. Instead, they relayed that they also are overworked.

However, one senior official was willing to go on the record.

“ASHAs do the majority of the health department’s work, and they are massively underpaid for their duty,” said Dr. Jessica Andrews, a medical officer at Kolhapur’s Shiroli Primary Health Center. She has been handling mental health cases. “Without them, the health system will collapse.”

‘Not Treated As Humans’

Several ASHAs across India have worked for over a year without a break. One of them is Pushpavati Sutar, 46, diagnosed with hypotension (low blood pressure) and diabetes within seven months of COVID-19 duty in November 2020. Like Khade, she experienced constant spells of dizziness.

“Often, there was fake news of community COVID transmission in my area,” she said.

Every day, senior officials at the health center hounded her to find more details about such instances.

An ASHA for 13 years, she’s never made an error in her surveys and was sure of no community transmission. “After investigating, I found that the accused was COVID negative. Instead, two of his relatives were positive.”

She had to clear such misconceptions almost every day, answer senior officials’ questions, collect records and perform her regular duty. “For several days, I couldn’t sleep,” she remembered.

Further, fearing COVID-19 guidelines and quarantine rules, community members began demanding ASHAs hide COVID-19 cases. “People even accused us of spreading COVID as we would survey the entire village,” Sutar recounted. Moreover, she said senior officials asked ASHAs to visit the families of COVID-19 patients—instead of allowing data collection over the phone—putting them at risk of infection.

“At several places, there have been instances of community violence, where ASHAs were beaten up,” said Patil, who has filed legal complaints on behalf of the assaulted workers and is helping them mentally recover.

Kolhapur’s ASHA union has written to several government authorities, including Maharashtra’s chief minister and Indian Prime Minister Narendra Modi, highlighting the mental toll of COVID-19 duty. Still, none of their letters have garnered a helpful response.

“Forget adequate pay,” said Khade, as she continued surveying, juggling between completing her task and trying to keep her mind at ease. “We are not even treated as humans.”

ASHA Rehana Mujawar from Maharashtra’s Tardal village shows the COVID records she has to fill every day by visiting her community of over 1000 members / credit: Sanket Jain — ASHA Rehana Mujawar, of Maharashtra’s Tardal village, shows COVID-19 records she is required to fill out every day by visiting her community of over 1,000 members / credit: Sanket Jain

ASHA workers Rekha Dorugade and Mandakini Kodak trekking the Dhangarwada hill to complete their survey, a steep patch of five kilometers in Kolhapur’s Pernoli village / credit: Sanket Jain — ASHA workers Rekha Dorugade and Mandakini Kodak trekking the Dhangarwada hill to complete their survey, a steep patch of 5 kilometers (3.1 miles) in Kolhapur’s Pernoli village / credit: Sanket Jain

An ASHA worker took a selfie as part of their protest on 21 July 2021 in Maharashtra’s Kolhapur city / credit: Sanket Jain — An ASHA worker took a selfie as part of their protest on July 21 in Maharashtra’s Kolhapur city / credit: Sanket Jain

ASHA workers protesting outside the district collector’s office in Kolhapur city with placards mentioning their workload. In the center with a red saree is ASHA union leader Netradipa Patil, who has been fighting for better working conditions for over a decade / credit: Sanket Jain — ASHA workers protest outside the district collector’s office in Kolhapur city with placards mentioning their workload. In the center, wearin a red saree, is ASHA union leader Netradipa Patil, who has been fighting for better working conditions for over a decade / credit: Sanket Jain

ASHAs across India have been protesting for better pay, the status of full-time workers, and proper working conditions. However, their protests haven’t seen concrete results yet / credit: Sanket Jain — ASHAs across India have been protesting for better pay, obtaining the status of full-time workers and proper working conditions / credit: Sanket Jain

India merely has 810 district hospitals for 833 million rural people. In mountainous regions like Kolhapur’s Masai Pathar, ASHAs often trek, risking their lives to save pregnant women and make healthcare facilities accessible / credit: Sanket Jain — India has 810 district hospitals for 833 million rural people. In mountainous regions like Kolhapur’s Masai Pathar, ASHAs often trek, risking their lives to save pregnant women and make healthcare facilities accessible / credit: Sanket Jain

An ASHA worker explains breastfeeding and taking care of the newborn to a community woman in Maharashtra’s Khutwad village / credit: Sanket Jain — An ASHA worker explains breastfeeding and taking care of a newborn to a community woman in Maharashtra’s Khutwad village / credit: Sanket Jain

In Kolhapur’s Khutwad village, ASHA Maya Patil informs a migrant sugarcane cutter whose relative gave birth to a child a month ago about postnatal care and how they can avail of the public healthcare facilities / credit: Sanket Jain — In Kolhapur’s Khutwad village, ASHA Maya Patil informs a migrant sugarcane cutter, whose relative gave birth to a child a month ago, about post-natal care and how they can access public healthcare facilities / credit: Sanket Jain

To inspire fellow ASHAs, Netradipa Patil shares a WhatsApp status quoting lyricist and poet Gulzar, “Milta To Bahut Kuch Hai Is Zindagi Me, Bas Ham Ginti Usi Ki Karte Hain, Jo Hasil Na Ho Saka. (We get many things in life, but we only count the things we couldn’t achieve) / credit: Sanket Jain — To inspire fellow ASHAs, Netradipa Patil shares a WhatsApp status quoting lyricist and poet Gulzar: “Milta To Bahut Kuch Hai Is Zindagi Me, Bas Ham Ginti Usi Ki Karte Hain, Jo Hasil Na Ho Saka. (We get many things in life, but we only count the things we couldn’t achieve) / credit: Sanket Jain

ASHAs also distribute iron, calcium, and vitamin tablets, among others, to the community women and children every month. “For distributing these medicines, we’re merely paid Rs 100 (USD 1.3),” says ASHA Netradipa Patil / credit: Sanket Jain — ASHAs also distribute iron, calcium, and vitamin tablets, among others, to community women and children every month. “For distributing these medicines, we’re merely paid Rs 100 (USD 1.3),” says ASHA Netradipa Patil / credit: Sanket Jain

ASHA Prajakta Khade collected the sputum of a patient she suspects to be a Tuberculosis patient / credit: Sanket Jain — ASHA Prajakta Khade collected the sputum of a patient she suspects to be a tuberculosis patient / credit: Sanket Jain

“Be it any health record, the health department relies on our surveys and fieldwork,” says Prajakta Khade, who has been an ASHA since 2009 / credit: Sanket Jain — “Be it any health record, the health department relies on our surveys and fieldwork,” says Khade, who has been an ASHA since 2009 / credit: Sanket Jain

Women often share their health and mental issues with ASHA workers as they have built a safe bond over the past decade / credit: Sanket Jain — Women often share their health and mental issues with ASHA workers, as they have built a safe bond over the past decade / credit: Sanket Jain

As part of the Health Ministry’s program of alleviating Non-communicable diseases, ASHAs across Maharashtra are tasked with surveying communities by asking them over 60 questions. “We will merely be paid Rs 5 (0.06 USD) per form for collecting and filling in all the details,” says Khade / credit: Sanket Jain — As part of the Health Ministry’s program of reducing non-communicable diseases, ASHAs across Maharashtra are tasked with surveying communities by asking them more than 60 questions. “We will merely be paid Rs 5 (6 U.S. cents) per form for collecting and filling in all the details,” says Khade / credit: Sanket Jain

A significant part of ASHA Prajakta Khade’s time goes into writing the medical records. “If any record is incomplete, our seniors immediately probe an inquiry, and even the pay is deducted,” she says / credit: Sanket Jain — A significant part of Khade’s time goes into filling out by hand medical records. “If any record is incomplete, our seniors immediately probe an inquiry, and even the pay is deducted,” she says / credit: Sanket Jain

So far, Prajakta Khade has spent over Rs 10000 (USD 131) on doctors, medical tests, and medicines, an equivalent of three months of her salary. “ASHAs don’t receive any health support system from the Government, nor any medical insurance,” she says / credit: Sanket Jain — So far, Khade has spent over Rs 10000 ($131 USD) on doctors, medical tests, and medications, an equivalent of three months of her salary. “ASHAs don’t receive any health support system from the government, nor any medical insurance,” she says / credit: Sanket Jain

ASHA Jayashree Khade from Kolhapur’s Vhannur village tested positive for COVID in May 2021. “None of my seniors even once asked about my health. It was only the fellow ASHAs who helped me,” she says / credit: Sanket Jain — ASHA Jayashree Khade from Kolhapur’s Vhannur village tested positive for COVID-19 in May 2021. “None of my seniors even once asked about my health. It was only the fellow ASHAs who helped me,” she says / credit: Sanket Jain

Prajakta Khade gives a plastic bottle to a community woman asking her to submit the sputum for tuberculosis detection / credit: Sanket Jain — Prajakta Khade gives a plastic bottle to a community woman asking her to submit sputum for tuberculosis detection / credit: Sanket Jain

Pushpavati Sutar, as part of postnatal visits, often counsels the women on breastfeeding, seeks constant updates on the mother and newborn’s health, and provides them the required medicines / credit: Sanket Jain — Pushpavati Sutar, as part of postnatal visits, often counsels women on breastfeeding, seeks regular updates on the health of both the mother and the newborn, and provides the required medicines / credit: Sanket Jain

An ASHA worker filling the health records of a newborn in Kolhapur’s Shirol region, noting down important details / credit: Sanket Jain — An ASHA worker filling out health records of a newborn in Kolhapur’s Shirol region, noting important details / credit: Sanket Jain

Pushpavati distributes iron and folic acid tablets to her community members / credit: Sanket Jain — Sutar distributes iron and folic acid tablets to her community members / credit: Sanket Jain

To make sure the community members take medicines as per the schedule, ASHAs often write instructions on the box / credit: Sanket Jain — To ensure community members take medicines as per a schedule, ASHAs often write instructions in the native language on the box / credit: Sanket Jain

Pushpatai ignored her hypotension symptoms for several months and continued the survey because of the tremendous workload / credit: Sanket Jain — Sutar ignored her hypotension symptoms for several months and continued the survey because of the tremendous workload / credit: Sanket Jain

ASHA workers always counsel the community members on proper healthcare. Here Pushpatai is talking to a woman about early childhood health in Kolhapur’s Shirol region / credit: Sanket Jain — ASHA workers always counsel community members on proper healthcare. Here, she is talking to a woman in Kolhapur’s Shirol region about early childhood health / credit: Sanket Jain

As part of the health ministry’s Anemia free India program, ASHAs are given a long notebook to maintain the records of 6-51 week old infants and 5-10-year-old children from their community. ASHAs regularly provide them with adequate medicines to prevent Anemia / credit: Sanket Jain — As part of the health ministry’s Anemia Free India program, ASHAs are given a long notebook to maintain the records of 6- to 51-week-old infants and 5- to 10-year-old children from their community. ASHAs regularly provide tablets to prevent anemia / credit: Sanket Jain

ASHAs’ role doesn’t end with distributing medicines. People ask them several doubts about medicines, and they patiently answer all of them / credit: Sanket Jain — ASHAs’ role doesn’t end with distributing medications. They answer questions people raise / credit: Sanket Jain

ASHA Rani Koli from Kolhapur’s flood-affected Bhendavade village surveying her community after the July 2021 floods. “Even my house was ravaged by the 2019 and 2021 floods, but we keep working to make sure everyone remains safe,” she said / credit: Sanket Jain — ASHA Rani Koli, from Kolhapur’s flood-affected Bhendavade village, surveying her community after the July floods. “Even my house was ravaged by the 2019 and 2021 floods, but we keep working to make sure everyone remains safe,” she said / credit: Sanket Jain

ASHA Kavita Patil talking to senior citizens in Kolhapur’s Bhendavade village to understand the mental toll of two floods / credit: Sanket Jain — ASHA Kavita Patil talking to senior citizens in Kolhapur’s Bhendavade village to understand the mental toll of living through two floods / credit: Sanket Jain

ASHA workers Netradipa Patil and Maya Patil surveying a community to learn more about how two floods and lockdowns affected the lives of rural community women / credit: Sanket Jain — ASHA workers Netradipa Patil and Maya Patil surveying a community to learn more about how two floods and lockdowns affected the lives of rural
community women / credit: Sanket Jain

Sanket Jain is an independent journalist based in the Kolhapur district of the western Indian state of Maharashtra. He was a 2019 People’s Archive of Rural India fellow, for which he documented vanishing art forms in the Indian countryside. He has written for Baffler, Progressive Magazine, Counterpunch, Byline Times, The National, Popula, Media Co-op, Indian Express and several other publications.