As coronavirus started to rage in India last year, ASHA (accredited social health activist) workers were touted as COVID-19 warriors and frontline soldiers fighting the pandemic at the grassroots level. One year on, the gap in the supply of safety essentials such as masks, sanitizers and Personal Protective Equipment (PPE) kits, acute work pressure from the department, hostility from locals and work-life disbalance have left them in the middle of an unfolding mental health doom.
“I have been having suicidal thoughts lately. The government officials didn’t just snatch my work but my dignity too. Apart from this, they created a sense of fear amongst other ASHA workers that no one is ready to take a stand for me. I have had enough of the abuse and don’t know what to do anymore to save my honor,” bemoaned 45-year-old Anju Bala, with her voice breaking down midway. The former Ambala president of Haryana ASHA Worker Union was terminated this year after more than a decade of service.
Working under pressure in the pandemic
Bala has been accused of substandard work and ‘bad behavior’— an allegation she strongly rejects. She alleges that she’s being targeted for being the force behind a series of statewide protests in Haryana since 2018. This isn’t the first time she’s at the receiving end of the stick for demanding basic rights for ASHA workers like safety gear and increased wages among other things. “I have been targeted for staging dharnas and speaking to the media against the fake claims of ministers and bureaucrats,” adds Bala. She comes from an extremely deprived household where her husband is disabled, and one of her two sons had to quit his studies after she was fired while the other one lost his job.
Bala’s story isn’t an anomaly.
Several among the 22,000 ASHA workers from Haryana have been dealing with similar cases of discrimination and maltreatment at the hands of the authorities regularly and the pandemic has only worsened it leaving a huge impact on their mental health. At a time when a section of our society can find some much-needed peace in their work-from-home regime during these devastating times, ASHA workers are denied even basic rights let alone any luxury.
They are not only expected to meet daily targets of door-to-door surveys for data capturing but are also to be relentless in their efforts to upscale the inoculation drive in the rural belt. Amid rumors and myths resulting in vaccine hesitancy, the rural demographic has not exactly been friendly to the inoculation drive. Lack of concerted efforts from the state to assuage fears among villagers has only added to the woes.
An ASHA worker from the Bhiwani district of Haryana, Binita Devi recalls the grueling work conditions. “The stress arises from both parties — the government and the locals — for testing and vaccinating populations. But we have learned to deal with it. What bothers me though is the struggle I undergo at the end of every month, when I fill my performa and take it to my senior, the Auxiliary Nurse Midwife (ANM) to sign it, she does it unwillingly after denying and delaying it for several days. It is a constant struggle.”
Devi earns between Rs. 7,000 - Rs. 9,000 every month and says that her income means a lot to her since she calls it her ‘ticket to financial freedom’. “There are no jobs currently and I feel it’s better to do this work than any other work as I am not qualified enough to do any clerical job,” says Devi, whose husband is a construction worker.
In May this year, ASHA workers of Haryana organized a mass protest in which thousands of them decided to boycott work until their demands were met. They also reportedly submitted a memorandum addressed to the Prime Minister, alleging “inhumane” working hours, non-payment of salaries and allocation of technical tasks that they aren’t equipped to perform among other issues. However, their protest went unregistered by the government.
“There have been instances where when the survey duties were being allocated, some ASHA workers’ families denied sending them out for duty. In one of the cases, this led to the termination of an ASHA worker, and we had to struggle a lot to get her re-appointed. The department builds acute pressure on ASHAs. It’s no longer considered volunteer work but has become a mandatory duty for ASHA workers, while in reality, we remain volunteers with no special benefits unlike those who are permanently employed with the government. How is this fair?” asks Surekha, general secretary of the ASHA Workers Union, Haryana.
Work-Life balance gone awry
“The department expects us to deliver on short notices and while fulfilling that we skip on our home-bound duties,” points out Surekha. “We have been facing this major mental conflict since last year when the work pressure started increasing manifolds leaving us little time for our home, husband, and children. Leaving our work as ASHAs will cost us the little financial freedom we have secured for ourselves over the years, however, delayed it may be, but the ongoing work stress has only created a rift in our personal and professional life,” she laments.
ASHAs, as women in any other profession, also have to deal with the patriarchal mindset of people. Unlike their urban counterparts, they work in societies and communities far more regressive. Sunita Devi, an ASHA worker from Sonipat in Haryana, along with her two children has been living with her parents for the last 17 years. She got divorced two years ago but this difficult reality of her life has always overshadowed her work and the taboo against divorce has forever impeded it.
“A single woman always has to suffer double the hardships. Our society discriminates between men and women and especially when a woman comes back to her parent's house with her children. While my family supported me in my decision of working as an ASHA, I was always alarmed, initially, to go on the field, fearing the eyes of men in the village and the conversations I would evoke among people,” she recalls.
“Besides being subjected to the male gaze, I had to brave constant judgment. I was labeled as a woman who has ruined her life and has now come to influence our (village) women as well and ruin our houses too. This is when I visit their houses as part of my work as an ASHA,” shares Sunita, who fought for seven years to get a divorce and is still fighting a case to secure maintenance for her children from her ex-husband.
While being a single working woman in Haryana’s villages isn’t less stressful by any measure, increased work pressure also leads to distress back at home. “My mother scolds me sometimes for being out for work all day. She rebukes me for not lending a helping hand at home but it really takes a toll not just on my physical health, but I feel mentally exhausted too,” she says, adding that it’s difficult to stay happy, motivated and at peace in an environment of angst at home.
Fear of PTSD looms over ASHAs
COVID-19 has only added to the ongoing struggles of ASHAs who work as frontline workers among communities lacking awareness and being more susceptible to rumors. Reports of them being thrashed and chased out of homes where they have to visit for testing and surveying have been guiding headlines across the media. Yet, their awful situation of being stuck between a rock and a hard place with financial distress and workplace harassment does not allow them a choice to quit. Add to this, the fear of being infected and dying of coronavirus.
“Dying of coronavirus is better than dying of hunger,” says an exhausted Anita, an ASHA worker from Haryana’s Jhajjar.
Havovi Hyderabadwalla, a clinical and forensic psychologist, sheds light on how ASHA workers’ mental health is impacted due to the nature of their work and the ongoing misconduct that they have to face because of their work. “ASHA workers largely go through a lot of depression, anxiety and Post Traumatic Stress Disorder (PTSD) and these issues don’t just get triggered at work, the sufferer takes them home as well. And because there is so much resistance against issues of mental health, it’s hardly discussed and treated,” says Hyderabadwalla.
ASHA workers are grossly undervalued, underserved and underpaid and there’s hardly any conversation around their mental health. Help available to treat mental health issues in the form of psychologists and psychiatrists is also dire.
For every 1,00,000 individuals, India only has 0.3 psychiatrists, 0.12 nurses, 0.07 psychologists and 0.07 social workers as per a World Health Organisation (WHO) report published in 2020. Ideally, we need at least three psychiatrists and psychologists per 1,00,000 population. The report further estimated that 7.5% of Indians suffer from some mental disorder and that nearly 20% of India is likely to suffer from mental illnesses by the end of 2020.
Immediate intervention required
The various concerns have driven ASHAs to fatigue and burnout. While their essential service in the state's fight against the COVID-19 crisis is critical, they deserve basic rights and access to mental health services. The government needs to make rapid decisions to relieve them from the constant state of fear and stress.
Psychologist Hyderabadwalla foresees that the current situation of ASHA workers where they aren’t supported with mental health treatment and diagnosis will cripple them at some point. “One can still cope with physical ailment if their mental faculties are together whereas if one, figuratively, loses their mind, they lose everything. One can be a healthy person physically but if one is suffering mentally then it will lead to them being unproductive, burned out and completely lost,” she adds.
The government must start with mental health screening of ASHA workers and if they are found suffering from stress, anxiety, depression, or PTSD then the continuous screening will be imperative. It should provide follow-up screening sessions to monitor their progress and provide the necessary support. As Hyderabadwalla reminds, support groups are another great way to deal with mental health issues.
While the conversation around ASHAs’ mental health issues needs to gain serious momentum, the recent mandate directing ASHA workers to download a mobile phone application introduced by the National Health Mission has only heightened their worries. They are being forced to download the MDM 360 shield app on their smartphones and update their daily target on it. ASHAs worry that this app will be used as a surveillance app to monitor their phones adding to the oppressive air of fatigue and fear.
(Edited by Sanhati Banerjee)