Commentary | Jayabrata Sarkar, Sentinels on the Covid-19 Battlefield: The Costs of Accredited Social Health Activist Care Work in India
The immediate national lockdown announced by the Indian government on March 24, 2020 to control the spread of the coronavirus may have initially prevented a breakdown of the health care sector. But it exposed a major crisis in a public health care system incapacitated by the virtual non-existence of treating infections. Private clinics and private hospitals operated and curtailed healthcare services on their own volition, driving up health costs and even engaging in underhand profiteering till the government capped the coronavirus health charges.
“The enormity of care work came for the health volunteers at a huge socioeconomic and psychological cost.”
Faced with the fast spreading coronavirus, Accredited Social Health Activists (ASHA), numbering approximately one million, with expertise in mother-child healthcare, were transformed into impromptu first responders to fulfill the Indian state’s emergency health objectives to contain the coronavirus pandemic. Over few months, under grave risk, ASHA’s impressive fulfillment of health safety measures proved invaluable to the government in its fight against the pandemic. Yet, the enormity of care work came for the health volunteers at a huge socioeconomic and psychological cost.
ASHA and the Pandemic Health Emergency
In the health crisis situation, ASHA workers were directed to follow the Ministry of Health and Family Welfare’s Standard Operating Procedures. Scores of ASHA workers attended hastily organized training sessions in preparation for the “war against the coronavirus.” But those in rural and remote areas faced difficulties attending the training sessions due to poor internet connectivity. Nevertheless, determined and resourceful ASHA workers, with a reputation of care work in their respective villages, still found ways to access online training modules through WhatsApp and phone calls with their local health supervisors, and through TV and radio. With training sessions limited to a fortnight, ASHA employees, a moderate number of whom were vaccinated, were thrust into the Covid-19 battlefield in cities, towns and villages across India.
At the ground level, due to a shortage of testing kits and lack of health centers ASHA workers used a symptom-based surveillance approach to trace and quarantine suspected Covid-19 patients. It entailed each ASHA worker to visit on average of 50-100 houses every day, often within containment zones, with thermal scanners and pulse oximeters to test-trace-isolate-support (TTIS) suspected Covid 19 patients. A high proportion of Covid-19 patients were members of the great mass of unemployed returnees who had returned to their villages from urban centers and for whom it was impossible to maintain social distancing. After identifying Covid-19 cases, ASHA workers treated quarantined patients at home with anti-coagulants and bronchodilators through nebulization and steroids and intravenous oral medicines to stabilize their physical condition. This became the norm at the height of the pandemic when patients were refused admission in overflowing district hospitals and institutional quarantine centers. Simultaneously, ASHA workers persuaded villagers to install the Aarogya Setu App, a self-monitoring health software application from the Indian government meant to track individual health status and allow timely healthcare support. Digital initiatives continued with social distancing interventions and house and lane visits from government sanitary officials and the local police to ensure regular garbage cleaning and sanitation of drains, lanes, public toilets, and common spaces to contain the spread of coronavirus. To stave off a humanitarian disaster, ASHA health staff developed supply chains to deliver essential items such as food packets, grocery bags, cash handouts, and medicines to elderly widows, pregnant women, differently abled and children under five years.
Yet, implementing pandemic safety health services coincided with proliferating misinformation and myths about the coronavirus which had been passed through numerous WhatsApp messages among villagers. Astounding superstitious beliefs gripped the villagers: that “it was advisable not to get a vaccine while menstruating”; “to avoid the sun for a week after getting vaccinated”; “oxygen levels would rise if camphor was snorted and that an onion-rich diet could keep the coronavirus away.” To counter this misinformation, ASHA workers endorsed doctors’ advice by posting videos and newspaper clippings on WhatsApp groups they had created among villagers. The health workers also provided a scientific explanation to a proper diet and medication and persuaded villagers to get vaccinated for Covid-19 by sharing on WhatsApp groups photographs of getting vaccinated.
ASHA Employees: Socio-Economic and Psychological Stress
As pandemic health care measures bore success, the Indian government, national media and the Indian Medical Council hailed ASHA workers as “foot soldiers of the (Covid-19) battle,” “corona warriors,” the “first line of defense,” etc. Prime Minister Narendra Modi urged the quarantined and gated middle class to acknowledge health workers symbolically by clapping, ringing bells or beating pots or plates. Yet the fight against the pandemic had a crude market logic to it. Across India, state-level health authorities extracted care-work by transforming ASHA volunteers into piece-rate workers who would receive piece-rate payment upon successful fulfilment of pandemic health goals. Workplace environment and operational logistics contributed to negligent occupational safety, leading to health risk, emotional stress, and anxiety among ASHA health employees. Many health workers did not receive standardized protective equipment from the local health officers. Left with no choice, they wrapped shawls, scarves, or handkerchiefs around their faces and hoped that would protect them. They could not access safe drinking water, toilets, or proper food or medical transportation services.
ASHA worker’s emotional distress was aggravated by stressful conditions prevalent at home. At home with unemployed spouses, the delayed stipend that ASHA employees received was a pittance of ₹1,000 (US$12.24). Without the honorary remuneration from their traditional health service it was too little to run a household. In such a precarious financial situation many ASHA health workers reported significant debts. There were several instances when ASHA workers had to pawn their intimate belongings to manage household expenses. They had to cook for their children as mid-day meal schemes became unavailable from mother-child rural care centers and construction sites where their husbands worked as unskilled laborers shut down. They stayed away from family members, including their own children, for fear of coronavirus infection. What was most unfortunate was that their husbands mimicked the public perception of health workers who needed to be stigmatized. Social censure of health workers translated into insecure public workspaces. Reports filed by ASHA staff mention incidents where groups of villagers would chase them away, physically and verbally assault them, spitting on and pelting them with stones.
After much delay the Indian government notified states to disburse insurance payouts to ASHA workers who had worked continuously for three months. Yet insurance claims were impeded by bureaucratic loopholes and requirements for a police “firsthand information report” (FIR) to be submitted to the concerned public functionaries. But then a question arose that reflected a cruel irony: who could file an FIR if an ASHA worker died? Would it be the next of kin? Often, the death of a health worker went unrecorded. Death stalked ASHA workers in other ways: utter negligence and discriminatory mindsets meant that those health volunteers who were infected with the Covid-19 virus were not tested. Doctors at the Covid health centers refused to treat them. Eventually ASHA volunteers were left to their own fate.
Conclusion
To highlight their precarious working condition, approximately 600,000 ASHA workers participated in a historic two-day national protest between August 7-9, 2020. The strike highlighted demands of the ASHA worker: a minimum wage of ₹ 12,000 (€134); a ₹10,000 (€111) lockdown allowance; protection kits; immediate arrear payment; and guarantees from government health agencies of prompt and adequate compensation to their families if they were injured, infected, or died during pandemic health care service. The protest succeeded in having an impact, as the central government hastily initiated financial compensation and payment schemes for the ASHA workers. But such spasmodic measures and temporary resolutions cannot address the iniquitous structural dynamics of the Indian health sector.
What must be done to advance the cause of the frontline healthcare professionals? To begin, it is of absolute necessity to initiate interactive sessions that would develop into a forum for street-level health care professionals to voice their myriad concerns about workspaces, service conditions, and even counselling if faced with the prospect of an emotional burnout. Leaders in the healthcare sector must seek to address health workers’ concerns and mitigate them as much as they can. Considering the extraordinary difficult circumstances under which emergency health measures were implemented, the political regime and health institutions must express admiration and gratitude to, and display compassion for, frontline health employees, while stopping the practice of exteriorizing healthcare to the public as a way to build political capital.
Finally, the visibility of “invisible” and perpetually “temporary” ASHA staff during the Covid-19 health mission must be a stimulus to substantially improve employment conditions of healthcare workers. The political leadership must reimagine health care workers so they are no longer considered to be laborers whose pay is based on performance but considered as a distinct category of public functionaries with regular emoluments. Further, it is of utmost necessity to initiate quicker disciplinary proceedings against health officials who refuse to forsake social discriminatory attitudes in the workplace. Dismissive and discriminatory behaviour was rampant during ASHA workers interaction with local health bureaucracy during the Covid- 19 pandemic.
Dr. Jayabrata Sarkar is an Associate Professor employed in Deshbandhu College, University of Delhi. His research areas include marginality, exclusion, identity politics, nationalism, and populism.
To cite this essay, please use the entry suggested below:
Jayabrata Sarkar, “Sentinels on the Covid-19 Battlefield: The Costs of Accredited Social Health Activist Care Work in India,” criticalasianstudies.org Commentary Board, June 5, 2023; https://doi.org/10.52698/PEVZ7669.