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Beaten, burnt out and broke: How Haryana's ASHA workers, on frontlines of fight against COVID-19, are coping

Suman, 17, was cooking lunch when a man wielding a steel pipe barged into her home and hit her on the head. The motive was revenge: Suman's mother, Usha, an Accredited Social Health Activists (ASHAs) worker in Butana Kundu village in Sonipat, Haryana, had stuck a home quarantine notice outside the man's home two days ago as part of her COVID-19 duty.

Usha is one of over 10 lakh ASHAs who connect India’s rural population to its public healthcare system as a part of the country’s National Health Mission (NHM). Her pre-pandemic job role, which included over 60 tasks — from vaccinating newborns to taking care of expecting women, and advising them on family planning — has been entirely re-written during COVID-19.

Now, she is expected to conduct door-to-door preliminary surveys for the infectious disease, inform healthcare authorities if anyone shows symptoms or returns from outside the village, and spread awareness on hygiene and social distancing norms.f

So, when a woman in Usha’s neighbourhood returned to her home from outside Butana on 1 May, she informed the authorities at the Primary Health Center (PHC). “They asked me to tell her to quarantine herself at home and put a sticker on her front gate. Even though my job is only to inform them, I followed orders, but the family simply tore the sticker,” Usha said.

The next day, as Usha was replacing the sticker, the mother of the returnee rushed outside and pushed her. “She abused me and told me to stop harassing their family. She slapped me and then bit me on my palm saying ‘ab hoga tujhe corona, tu dekh’ [now you will get the coronavirus infection, you see],” Usha recounted.

At the PHC, she received a tetanus shot for her bite after which she went back to work. The health authorities told her they'd take care of the offending family.

Two days later, when Usha was out doing surveys, a young man from that family went to her house and hit her daughter. This,  revenge for ‘telling on them’ to the health authorities who paid them a visit and yet again put up the home quarantine notice on their gate.

“I took Suman in a 108 ambulance to PGI‌ (Post Graduate Institute of Medical Education & Research)‌ Gohana, where they refused to admit her saying there were too many COVID-19 patients. They referred her to PGI Khanpur, which then referred her to PGI Rohtak. Even they said the same thing and sent us back home with some painkillers for Suman. They didn’t even give us a government ambulance to go back. I paid Rs. 1,700 for a private one,” Usha recounted. 

For two days, Suman was mostly unconscious and Usha was convinced she was going to lose her daughter. A widow and mother of four, working a job that provides her with meagre pay, Usha simply could not afford to take Suman to a private hospital. 

Efforts of the Haryana ASHA Workers’ Union helped news of the incident spread on social media on 5 May. The state health department was pressured into ordering the PHC to tend to Suman at home.

“She’s better now. But she doesn’t say anything, doesn’t smile and can’t even sit. Even after serving my people, my country, this is what I‌ get. Barely any money, no protection, an injured child. I’ve failed as a mother and the health ministry has failed me,” Usha said, breaking down.

Sunita Rani, an ASHA from Nathupur village in Sonipat and also a union leader, is far more specific in placing the blame. “The government’s communication plan and awareness campaigns around COVID-19 have been really weak. They created stigma along religious lines after the Tablighi Jamaat incident and divided Hindu-Muslim families. This only added to the casteism and classism we face. A huge portion of Haryana’s ASHAs belong to Scheduled Castes, are poor and are not very highly educated. People look down on us, thinking who are we to tell them how to live and where to go or not go,” she said. 

Yet another bias plays a role in the harassment and assault ASHAs are facing: gender. Pre-COVID, the men would go out to work and the ‌ASHAs would bond with the women over things they can’t otherwise discuss. But with the lockdown firmly in place, the men are at home; they often dismiss ASHAs who come knocking for COVID surveys as women who don’t know any better. 

Sheela, vice-president of the Haryana chapter of All India Democratic Women's Association, believes that the government has given ASHAs no tools to confront this multi-layered hostility and stigma on the front lines.

“We’ve been asked to go and check every street, day and night, with barely any protective equipment. People in our society harass us. On top pf everything, the police, who are out with us as we fight this disease – even they don’t cooperate. How are we supposed to work?” she asked. 

For Usha Rani, an ASHA‌ worker from Jagadhri city in Yamunanagar, Haryana, this non-cooperation from the police has cost her 23 times what the government is paying ‌ASHAs per month for their COVID-19 duties.

On 3 May, she was asked to conduct door-to-door surveys in Durga Garden, part of her village outside her ambit. In the absence of any public transport during the nationwide lockdown, a glaring sun overhead and reports of police beating up ASHAs caught walking to work, Rani resorted to asking her 15-year-old son Harsh to drop her on their bike.

Shortly into her fieldwork, she felt weak and faint and had to call him back to pick her up.

“The government has not arranged any transportation for us, despite expecting us to do COVID-19 surveys anytime, anywhere in this heat. What option did I have? But the traffic police stopped him at a checkpoint, fined him Rs 23,000 and forced him to sign the challan,” Usha Rani said.

Haryana’s ASHA‌ workers are paid Rs 2000 per month by the Central government, Rs 4,000 per month by the state government and are now receiving an additional Rs 1,000 a month for their COVID-19 duties.

“My husband died in an accident in the factory he worked at two years ago. The bike is in his name, and we lost all documents in a minor fire. I live with my aging mother-in-law and three children, the oldest of whom is Harsh. I am from a very poor family. I can’t afford this challan.‌ I request the authorities to cancel it, or the health department to pay it on my behalf since I was only doing my duty,” Rani added..

Pre-COVID, Rani would not have been assigned to do surveys at Durga Garden; ASHAs scope of work used to be limited to around 1,000 people in their neighbourhood.

Now, with India steadily climbing up the COVID-19 charts, they are also being assigned to different parts of their districts to cover densely-populated semi-urban and urban areas, and even unauthorised colonies.

In Kaithal district, two ASHAs have been deployed at every police check point along the Haryana-Punjab border to conduct temperature checks, make a list and submit a record at the end of each day.

“When the lockdown began, one ASHA worker and one Auxilliary Midwife Nurse (ANM) were deployed. Now, the ANMs have refused to do this duty and put it on us. From 7 am to 5 pm, we stand there in the sun. Our families have to drop us and pick us up and we pay for the fuel out of our own pocket,”‌ Saroj* (name changed), one of the ASHAs who has been travelling over 10 kilometres a day for her posting at one of the check points said.

Sunita pointed out that these additions to their initial COVID-19 roles‌ of conducting surveys, such as putting home quarantine notices and manning police checkpoints, happen either verbally or over WhatsApp. “No revised guidelines have been issued on what ASHAs have to do in this pandemic and how much they will be paid for it,” she added.

“We’re not even saying no to the work. But, the least the government could have done is given us transport, health department ID‌ cards and protective gear so we have some credibility and safety when we are sent out to quarantine people and deal with hostile men,” Sunita added.

Ranjana Narula, senior leader at Centre of Indian Trade Unions (CITU), has a longer list of basic provisions the government should have made before sending ASHAs out on the front lines of the COVID-19 fight.

“These women have to visit anywhere between 25 and 100 houses every day to conduct surveys. Many walk over 10 to 12 km daily in the sun, collect information, return to the PHC to submit it, then go back to check on suspected cases multiple times in a day. Apart from transport, the government should have the sense to provide water and meals,” she said. CITU demanded proper protective equipment – masks, gloves, shoe coverings, coats, sanitisers – for all ASHAs as early as March. “But even today, only some have it. Almost no one has gloves, coats, shoe coverings. Women use chunnis as masks. We know there is no shortage of funds between PM Cares and Prime Minister’s National Relief Fund (PMNRF). So why not allocate it where needed?” she wondered.

But that hasn't happened despite repeated demands from the union, even as the first case of COVID-19 has been confirmed among the state’s ASHAs. 

Omwati, from Dukheri village in Ambala, Haryana had been doing her daily COVID-19 surveys, as usual, using her chunni as a mask and with no gloves, when she developed a headache and felt faint. She gave her sample for a COVID-19 test the following day, after which she tested positive on 4 May. 

“I was immediately admitted to NM Hospital, Mullana. For four days, I was kept in a general ward with 30 to 32 migrant workers who were being tested for COVID. There was one common bathroom for men and women which was always dirty. I didn’t relieve myself for three days,” Omwati added.  

After she sent out this SOS video on 6 May, she was shifted to a cleaner ward on 8 May but she wants a separate room with a bathroom so she can recover quickly and resume her job as a community health worker.

“The government is treating doctors and us differently when we are as important a part of this fight against COVID as them. They are given better facilities when they test positive. Is it too much to ask for to be treated equally?” she asked. 

It would appear that way, given how Haryana chief minister Manohar Lal Khattar’s announcement doubling the salaries of all healthcare workers fighting COVID-19 did not include ASHAs.

And while he announced a Rs. 50 lakh life insurance for doctors, ASHAs and Angandwadi workers are only eligible for insurance worth Rs 10 lakh. Meanwhile, Omwati’s ASHA facilitator recently informed her that she wouldn’t be receiving any payment for May since she is ‘not working.’

“I’ve not taken a holiday. I got this disease because I was doing my job. Even now, other ASHAs who are stepping in for me and my ANM‌ keep calling me for information. I am working even in the hospital through my phone. And they’re saying they won’t pay me. How will I run my home?” Omwati asked.

Her husband, who used to work for a private contractor, has not been earning since the lockdown began either. He, along with their two children, were  tested for COVID-19 on 9 May. Their results are awaited.

“How can they deduct her payment? First they give ASHAs Rs 1,000 per month for COVID work, which is Rs around Rs. 33 a day. That’s laughable! Especially when you see that they can’t do any of their other incentive-based tasks such as holding family planning awareness meetings. They’re not deducting money from doctors or nurses who test positive, then why single out ASHAs?” Ranjana wondered.

The question is rhetorical. Ranjana is quick to provide an answer.

Because though they are the undisputed backbone of the health department, SHAs are essentially considered unpaid labour by the NHM, she said.

“Especially in COVID. Being used for contract-tracing, detection and awareness, ASHAs are the first line of defence. Without them, the whole operation would fall apart in no time,” she finished.

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Suman, 17, was cooking lunch when a man wielding a steel pipe barged into her home and hit her on the head. The motive was revenge: Suman's mother, Usha, an Accredited Social Health Activists (ASHAs) worker in Butana Kundu village in Sonipat, Haryana, had stuck a home quarantine notice outside the man's home two days ago as part of her COVID-19 duty. Usha is one of over 10 lakh ASHAs who connect India’s rural population to its public healthcare system as a part of the country’s National Health Mission (NHM). Her pre-pandemic job role, which included over 60 tasks — from vaccinating newborns to taking care of expecting women, and advising them on family planning — has been entirely re-written during COVID-19. Now, she is expected to conduct door-to-door preliminary surveys for the infectious disease, inform healthcare authorities if anyone shows symptoms or returns from outside the village, and spread awareness on hygiene and social distancing norms.f So, when a woman in Usha’s neighbourhood returned to her home from outside Butana on 1 May, she informed the authorities at the Primary Health Center (PHC). “They asked me to tell her to quarantine herself at home and put a sticker on her front gate. Even though my job is only to inform them, I followed orders, but the family simply tore the sticker,” Usha said. The next day, as Usha was replacing the sticker, the mother of the returnee rushed outside and pushed her. “She abused me and told me to stop harassing their family. She slapped me and then bit me on my palm saying ‘ab hoga tujhe corona, tu dekh’ [now you will get the coronavirus infection, you see],” Usha recounted. At the PHC, she received a tetanus shot for her bite after which she went back to work. The health authorities told her they'd take care of the offending family. Two days later, when Usha was out doing surveys, a young man from that family went to her house and hit her daughter. This,  revenge for ‘telling on them’ to the health authorities who paid them a visit and yet again put up the home quarantine notice on their gate. “I took Suman in a 108 ambulance to PGI‌ (Post Graduate Institute of Medical Education & Research)‌ Gohana, where they refused to admit her saying there were too many COVID-19 patients. They referred her to PGI Khanpur, which then referred her to PGI Rohtak. Even they said the same thing and sent us back home with some painkillers for Suman. They didn’t even give us a government ambulance to go back. I paid Rs. 1,700 for a private one,” Usha recounted.  For two days, Suman was mostly unconscious and Usha was convinced she was going to lose her daughter. A widow and mother of four, working a job that provides her with meagre pay, Usha simply could not afford to take Suman to a private hospital.  Efforts of the Haryana ASHA Workers’ Union helped news of the incident spread on social media on 5 May. The state health department was pressured into ordering the PHC to tend to Suman at home. “She’s better now. But she doesn’t say anything, doesn’t smile and can’t even sit. Even after serving my people, my country, this is what I‌ get. Barely any money, no protection, an injured child. I’ve failed as a mother and the health ministry has failed me,” Usha said, breaking down. Sunita Rani, an ASHA from Nathupur village in Sonipat and also a union leader, is far more specific in placing the blame. “The government’s communication plan and awareness campaigns around COVID-19 have been really weak. They created stigma along religious lines after the Tablighi Jamaat incident and divided Hindu-Muslim families. This only added to the casteism and classism we face. A huge portion of Haryana’s ASHAs belong to Scheduled Castes, are poor and are not very highly educated. People look down on us, thinking who are we to tell them how to live and where to go or not go,” she said.  Yet another bias plays a role in the harassment and assault ASHAs are facing: gender. Pre-COVID, the men would go out to work and the ‌ASHAs would bond with the women over things they can’t otherwise discuss. But with the lockdown firmly in place, the men are at home; they often dismiss ASHAs who come knocking for COVID surveys as women who don’t know any better.  Sheela, vice-president of the Haryana chapter of All India Democratic Women's Association, believes that the government has given ASHAs no tools to confront this multi-layered hostility and stigma on the front lines. “We’ve been asked to go and check every street, day and night, with barely any protective equipment. People in our society harass us. On top pf everything, the police, who are out with us as we fight this disease – even they don’t cooperate. How are we supposed to work?” she asked.  For Usha Rani, an ASHA‌ worker from Jagadhri city in Yamunanagar, Haryana, this non-cooperation from the police has cost her 23 times what the government is paying ‌ASHAs per month for their COVID-19 duties. On 3 May, she was asked to conduct door-to-door surveys in Durga Garden, part of her village outside her ambit. In the absence of any public transport during the nationwide lockdown, a glaring sun overhead and reports of police beating up ASHAs caught walking to work, Rani resorted to asking her 15-year-old son Harsh to drop her on their bike. Shortly into her fieldwork, she felt weak and faint and had to call him back to pick her up. “The government has not arranged any transportation for us, despite expecting us to do COVID-19 surveys anytime, anywhere in this heat. What option did I have? But the traffic police stopped him at a checkpoint, fined him Rs 23,000 and forced him to sign the challan,” Usha Rani said. Haryana’s ASHA‌ workers are paid Rs 2000 per month by the Central government, Rs 4,000 per month by the state government and are now receiving an additional Rs 1,000 a month for their COVID-19 duties. “My husband died in an accident in the factory he worked at two years ago. The bike is in his name, and we lost all documents in a minor fire. I live with my aging mother-in-law and three children, the oldest of whom is Harsh. I am from a very poor family. I can’t afford this challan.‌ I request the authorities to cancel it, or the health department to pay it on my behalf since I was only doing my duty,” Rani added.. Pre-COVID, Rani would not have been assigned to do surveys at Durga Garden; ASHAs scope of work used to be limited to around 1,000 people in their neighbourhood. Now, with India steadily climbing up the COVID-19 charts, they are also being assigned to different parts of their districts to cover densely-populated semi-urban and urban areas, and even unauthorised colonies. In Kaithal district, two ASHAs have been deployed at every police check point along the Haryana-Punjab border to conduct temperature checks, make a list and submit a record at the end of each day. “When the lockdown began, one ASHA worker and one Auxilliary Midwife Nurse (ANM) were deployed. Now, the ANMs have refused to do this duty and put it on us. From 7 am to 5 pm, we stand there in the sun. Our families have to drop us and pick us up and we pay for the fuel out of our own pocket,”‌ Saroj* (name changed), one of the ASHAs who has been travelling over 10 kilometres a day for her posting at one of the check points said. Sunita pointed out that these additions to their initial COVID-19 roles‌ of conducting surveys, such as putting home quarantine notices and manning police checkpoints, happen either verbally or over WhatsApp. “No revised guidelines have been issued on what ASHAs have to do in this pandemic and how much they will be paid for it,” she added. “We’re not even saying no to the work. But, the least the government could have done is given us transport, health department ID‌ cards and protective gear so we have some credibility and safety when we are sent out to quarantine people and deal with hostile men,” Sunita added. Ranjana Narula, senior leader at Centre of Indian Trade Unions (CITU), has a longer list of basic provisions the government should have made before sending ASHAs out on the front lines of the COVID-19 fight. “These women have to visit anywhere between 25 and 100 houses every day to conduct surveys. Many walk over 10 to 12 km daily in the sun, collect information, return to the PHC to submit it, then go back to check on suspected cases multiple times in a day. Apart from transport, the government should have the sense to provide water and meals,” she said. CITU demanded proper protective equipment – masks, gloves, shoe coverings, coats, sanitisers – for all ASHAs as early as March. “But even today, only some have it. Almost no one has gloves, coats, shoe coverings. Women use chunnis as masks. We know there is no shortage of funds between PM Cares and Prime Minister’s National Relief Fund (PMNRF). So why not allocate it where needed?” she wondered. But that hasn't happened despite repeated demands from the union, even as the first case of COVID-19 has been confirmed among the state’s ASHAs.  Omwati, from Dukheri village in Ambala, Haryana had been doing her daily COVID-19 surveys, as usual, using her chunni as a mask and with no gloves, when she developed a headache and felt faint. She gave her sample for a COVID-19 test the following day, after which she tested positive on 4 May.  “I was immediately admitted to NM Hospital, Mullana. For four days, I was kept in a general ward with 30 to 32 migrant workers who were being tested for COVID. There was one common bathroom for men and women which was always dirty. I didn’t relieve myself for three days,” Omwati added.   After she sent out this SOS video on 6 May, she was shifted to a cleaner ward on 8 May but she wants a separate room with a bathroom so she can recover quickly and resume her job as a community health worker. “The government is treating doctors and us differently when we are as important a part of this fight against COVID as them. They are given better facilities when they test positive. Is it too much to ask for to be treated equally?” she asked.  It would appear that way, given how Haryana chief minister Manohar Lal Khattar’s announcement doubling the salaries of all healthcare workers fighting COVID-19 did not include ASHAs. And while he announced a Rs. 50 lakh life insurance for doctors, ASHAs and Angandwadi workers are only eligible for insurance worth Rs 10 lakh. Meanwhile, Omwati’s ASHA facilitator recently informed her that she wouldn’t be receiving any payment for May since she is ‘not working.’ “I’ve not taken a holiday. I got this disease because I was doing my job. Even now, other ASHAs who are stepping in for me and my ANM‌ keep calling me for information. I am working even in the hospital through my phone. And they’re saying they won’t pay me. How will I run my home?” Omwati asked. Her husband, who used to work for a private contractor, has not been earning since the lockdown began either. He, along with their two children, were  tested for COVID-19 on 9 May. Their results are awaited. “How can they deduct her payment? First they give ASHAs Rs 1,000 per month for COVID work, which is Rs around Rs. 33 a day. That’s laughable! Especially when you see that they can’t do any of their other incentive-based tasks such as holding family planning awareness meetings. They’re not deducting money from doctors or nurses who test positive, then why single out ASHAs?” Ranjana wondered. The question is rhetorical. Ranjana is quick to provide an answer. Because though they are the undisputed backbone of the health department, SHAs are essentially considered unpaid labour by the NHM, she said. “Especially in COVID. Being used for contract-tracing, detection and awareness, ASHAs are the first line of defence. Without them, the whole operation would fall apart in no time,” she finished.

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