As India remains under a national lockdown to contain the spread of Covid-19, Urmila Patil, a 40-year-old Accredited Social Health Activist, or ASHA, goes door-to-door in the western Indian state of Maharashtra, conducting surveys, checking for coronavirus symptoms, and educating people about precautions.

Although on the frontlines of Covid-19 prevention and screening, Patil has received little formal training for the job, or protective gear like masks, gloves and sanitizers.

Worse, her own family has instructed her to stay away from their home, fearing that she might contract the virus and infect them in turn.

“They said that I was putting their lives in jeopardy, and that I should make alternative arrangements,” said Patil, a resident of the Surul village in remote Maharashtra. “On April 15, I visited a family that has been quarantined, as they’re suspected to be coronavirus carriers. Thereafter, my husband has made me sleep outside the house. That’s hardly safe, but what choice do I have?”

Patil is one of over 1 million ASHA (the word means “hope” in Sanskrit) workers who have been deployed as the first line of defense in the battle against the Covid-19 pandemic in India.

A crucial interface between the community and public health system in the South Asian country, these women health workers – usually aged 25 to 45 years – have been integral to the institutional healthcare structure in India for 15 years.

“The Foot Soldiers”

Recognizing the need to connect rural and marginalized communities with “accessible, affordable and quality” health care services, the Indian Ministry of Health and Family Welfare launched the National Rural Health Mission in April 2005, deploying ASHAs as the first port of call for any health-related demands of these sections of the population.

Their primary duties, according to the central government scheme, are ensuring institutional deliveries for expectant mothers, and maintaining sound maternal and neonatal health. However, over the years, ASHAs have been deployed to help fight a number of diseases, including dengue, leprosy, malaria, tuberculosis, and now, Covid-19.

“ASHAs are the foot soldiers in India’s battle against the dreaded Covid-19,” said K. Somashekhar Yadagiri, state president of the Karnataka ASHA Workers’ Union, which represents 42,000 ASHAs in the south Indian state.

“They are out there in the villages and slums all over the country since March 25, creating awareness about the pandemic, and collecting data on travel histories of people as well as coronavirus symptoms. The entire Covid-19 battle rests on the information and services they provide at the grassroots level.”

India has reported nearly 120,000 positive cases of Covid-19 and 3,600 deaths as of May 22.

“Abused, Assaulted, Pelted with Stones”

While many ASHAs have faced staunch opposition from their families for their health care work during the pandemic, others have encountered violence during their home-to-home surveys.

A mob of 100 people, for instance, assaulted a group of ASHA workers who were collecting data on people with cough, cold and fever symptoms in Karnataka in early April. Similar reports have also emerged from other Indian states, including Odisha, Telangana, Uttar Pradesh, Haryana and Bihar.

“These women health workers have been abused, assaulted, pelted with stones and spat on during their Covid-19 surveys in the past few weeks,” said Shankar Pujari, president of the Western Maharashtra ASHA Workers’ Union, which represents 70,000 ASHAs in the state.

“There is immense stigma attached to the disease, and people don’t want to declare symptoms, or that they could be Covid-19 carriers. When ASHAs approach them, they get irked and attack. Many others abuse them, suspecting that ASHAs might be infected as they’re constantly on the field.”

Responding to the attacks on health care workers, the Indian government approved amendments to The Epidemic Diseases Act of 1897 on April 22, making such crimes punishable with up to seven years of imprisonment and a fine of up to $7,000.

“No Formal or Elaborate Training”

In addition to the violence, a lack of training in handling Covid-19 is another roadblock for ASHA workers, said Dithhi Bhattacharya, executive head of the Delhi-based Centre for Workers’ Management, a nonprofit, pan-India organization focused on workers’ rights.

She stated that most of the training for ASHA workers from the central government has been limited to online sessions, which very few are able to access.

“As they are community workers, their education level is not to the extent where they are able to understand online communications,” said Bhattacharya. “You cannot expect these workers in remote villages, back of beyond India, to actually understand those instructions via an online medium…Some states like Kerala and Tamil Nadu are proactively training ASHAs in handling Covid-19, but we are not sure if other Indian states are following suit.”

Meera Negi, an ASHA worker in the north India state of Uttarkhand, told Direct Relief that before she started conducting Covid-19 surveys, she was called for a fifteen-minute briefing at a local hospital, where she was given instructions on how to conduct surveys, make notes, and create awareness about the novel pathogen.

“There was no formal or elaborate training, explaining the precautions or nuances,” said Negi, “Of course, I am scared, aware that I am at risk of contracting the virus. But I have to continue work for the health and safety of over 100 families that fall under my purview.”

“Every LIfe in this Population is at Risk”

A lack of personal protective equipment like masks, gloves and sanitizers is another major concern.

Shiva Dubey, president of the Uttarakhand ASHA Workers’ Association, said that when ASHAs first set out to conduct Covid-19 surveys in mid-March, they were given one disposable mask and half a bottle of sanitizer each. After the association voiced concern, the state helped the health workers with a bottle of sanitizer each and multiple single-use masks.

“Most ASHAs are responsible for a population of 1,000 to 1,100 each. Coronavirus surveys are especially challenging since every life in this population is at risk,” said Dubey, an ASHA worker since 2006. “So we make sure that we’re doubly precautious about our safety. In addition to the masks, we tie stoles around our mouths, and try to maintain distance even when surveying.”

In order to aid ASHA workers, nonprofit organizations like the Telangana-based Sulakshya Seva Samithi are distributing masks, sanitizers, immunity-building foods like peanut-jaggery bars, and energizers like almond milk among the community health workers.

Santhosh Manduva, the founder and president of the organization, said that the Indian government is taking every measure to ensure that essentials like masks and sanitizers reach ASHAs across the country.

“We have seen unfortunate cases where doctors and health care workers have been ill-treated, pressurized by landlords to vacate their homes as they suspect health care workers to be infected,” said Mandhuva. “But people must realize that these health care workers are risking their own lives for us. We need to protect them to protect ourselves.”

“Battling a Dangerous Disease”

ASHAs, who are treated as volunteers in lieu of permanent government employees, are not entitled to employment benefits like insurance, pensions, leave allowances or regularized salaries.

They receive performance-based incentives for healthcare delivery services instead of fixed salaries. For instance, the government pays them $4 for every institutional delivery that they facilitate in rural India, and $1.5 for full immunization of a child under one year.

For Covid-19-related outreach, the government has promised an honorarium of a little less than $15 per month for three months.

“Even as there is no clarity on what their entitlements are, ASHAs are on the frontlines, battling a dangerous disease. What happens if they fall ill? They have no workers’ rights, and are not recipients of government privileges,” said Bhattacharya.

Yadagiri, meanwhile, feels that ASHAs are working with “utmost commitment” during the ongoing crisis, and must receive all the support from their families, the society as well as the state.

“These are young women, many of them widows and divorcees, or women with small children and infants, yet working on Covid-19, risking their lives,” said Yadagiri. “Their dedication is exemplary. For instance, when ASHA workers were told by their Union not to start work unless they were provided protective masks, some did not heed. They tied kerchiefs to their faces and went to work in the villages.”

Dubey, the ASHA worker from Uttarakhand, voices the same zest. “I’m not bothered about the safety gear, honorarium or benefits,” she said. “I have been working amidst these people for 14 years. They are at risk now, and I must tend to them.”