Overworked, underpaid and vulnerable to infection, around 20,000 ASHA workers are practically the first line of defence against the contagion, especially in the Kashmir periphery. Given that they lack even the basics of rights as workers, they seemingly are an exploited lot, Farzana Nisar reports
As the afternoon sun shines brightly in the cloudless sky, Rafiqa Lolabi, 40-year old Accredited Social Health Activist (ASHA), hurriedly passes through the tortuous narrow lanes of the Sogam village in Kupwara. Donning a white disposable apron and a bundle of files in her hand, Rafiqa knocks at the door of every house and asks the inmates few questions about Covid-19 vaccination. She then jots down the important details in one of her files. This has been nearly the everyday practice of this woman for the last 14 years.
“My day starts at 10 am. I visit door to door to conduct different health surveys like keeping a record of pregnant women in our areas, immunization drives, assisting deliveries, etc. Our work also includes management of sick during home visits, creating awareness on health and providing necessary drugs and supplements to people,” Rafiqa said, hurriedly adding: “But this is not all.”
As the pandemic raged on, Rafiqa like thousands of other ASHA workers was deployed on Covid-19 duty. The Ministry of Health and Family Welfare assigned them the task of contact tracing, ensuring the infected people isolate, helming the vaccination drive and maintaining the records.
“We have been given the responsibility of providing the data from ground zero during this pandemic,” Rafiqa, who is also the district president of ASHA workers association Kupwara, said. “The expansion in our duties is not only tiring but risky too”.
Rafiqa’s 2006 decision to work as a social health activist was prompted by a double tragedy. Divorced twice, Rafiqa is the single mother of a 17-year-old son. In 1995, Rafiqa, a twelfth grader, was married to her cousin, but the marriage didn’t fetter her dreams of studying further. After convincing her in-laws, she was allowed to continue her studies.
“I wanted to study but my parents insisted on getting me married. I gave in to their will but also completed my graduation in the non-medical stream after marriage,” she said.
A year after marriage Rafiqa gave birth to her first child, but the happiness did not last long as their families came to know about the couple’s “milk kinship”. The couple then decided to part ways. (In Islam it is forbidden to marry if the boy and girl were nursed by the same woman when they were infants. Cousins can marry each other but not the milk brothers.)
“My ex-husband has the custody of my son, he is grown-up now and is currently pursuing engineering,” she said.
Undeterred by her divorce, Rafiqa worked as an employee at Bajaj Allianz Life Insurance Co Ltd and later as a mathematics teacher in different private schools of Kupwara and Handwara. She was also offered the post of supervisor in the Anganwadi department but rejected it.
“My father who was a headmaster by profession always thought I could do better. At that time, he wanted me to strive for a career in education,” she said.
Luckily, Rafeeqa was soon recruited as a Rehbar-e-Taleem teacher but the low salary couldn’t keep her hooked on to the job.
“Rs 1500 were not enough to meet my basic needs. But now when I see ReT teachers being regularized, I regret leaving the job.”
A few years later, Rafiqa got married to a man from her neighbourhood but fate had other plans. When she was pregnant with her son from the second marriage, she found out about her husband’s extramarital affair.
“Everything was going good until I caught him cheating on me. My world fell apart. I left him there and then,” she said.
Rafiqa’s ordeal did not end there. Soon after, her only brother died unexpectedly. “I don’t know the reason behind his death, but I know that he was mentally disturbed by the tragedies in my life,” she said. “After two divorces, his death was the final nail in the coffin.”
Knowing that she would now have to single-handedly raise her son, Rafiqa took the job of an ASHA worker. “I had lost all hope; my only motive in life was to look after my son”.
But little did she know, the monthly honorarium would be insufficient even for a hand-to-mouth existence.
As Rafiqa was preparing to go home at the end of a busy day, she received a phone call from her son, informing her about his pending tuition fee. The call deepened the worry lines on her forehead; as she does not have a single penny in her bank account.
“He is enrolled in a coaching centre at Hyderpora Srinagar and has to pay Rs 6000 to them. I assured him that I will provide him with the money but I don’t know how I am going to arrange it,” she said, as tears welled up in her eyes.
ASHA workers in Kashmir receive a monthly remuneration of Rs 2000 and some performance-based incentives, which at times raises the total income to some level of decency. For example, for every institutional child delivery, they are paid Rs 600.
“We get Rs 2000 for about eight tasks that we are bound to do perform. Besides, we get incentives for immunization, vaccination, training attendance etc. but this compensation system is very complex,” she said. “If we assist a woman throughout her pregnancy, and then due to some reason she delivers in a private hospital, we are not paid anything.”
Even after working for public healthcare for more than a decade, Rafiqa feels that workers like her are not given the recognition and monetary incentives that they deserve.
“What are we supposed to do with this little money? Spend on food, on health or on the studies of our children? A beggar earns much more than we do,” crestfallen Rafiqa said. “Even this amount is not released on time.”
Sharing her anguish, she recalls an Urdu couplet: Wo jis ka ek hi beta ho, bhooka aath pehron se, Batao ahl-e-danish, wo gundum lai ya Takhti lai? (Whose only son has been hungry for eight long hours, O ye wise men, Shall he seek wheat or the writing board?)
What concerns Rafiqa more, is the physical and psychological well-being of her son.
“I don’t have anyone except my son, he is my only asset but most of the time he remains emotionally disturbed because of the financial misery we face,” Rafiqa, who lives separately at her parents’ house, said.“He is in his teenage and I fear he might take some extreme step.”
Sharing The Crisis
In a dark room of an old mud house in Anantnag’s Khahpora hamlet, Shafiya, 19, is vigorously dragging on the hose of a hookah. She sporadically lets out a cloud of smoke in the room.
Shafiya, is the daughter of 40-year-old Shakeela Akhter, who has been working as an ASHA for the last 10 years. On being asked why her daughter smokes at such a young age, she points towards a bag full of medical reports. Shafiya is suffering from a neurological disorder since birth.
“Years back, a doctor at Jammu had advised her to smoke, since then she is addicted to it,” Shakeela said.
Although the medical condition of Shafiya requires full-time supervision, the strenuous work schedule precludes Shakeela from providing constant care to her.
“She faints and loses her consciousness every now and then,” sobbing Shakeela said. “No mother would ever want to leave her ailing child alone in the house, but my poverty compels me to do so”.
Shakeela’s meagre income supplements that of her husband, who works as a labourer at a band sawmill.
“I spend hours in the field and I prefer to walk miles than take a bus or cab,” Shakeela said. “The little amount of money that I get is used on my daughter’s medicines.”
Shakeela’s younger daughter, 12-year-old Muskaan is also facing the brunt of her mothers’ extended fieldwork. Shakeela said that Muskaan has to mostly skip her classes as the circumstances force her to look after her sister.
“Earlier, I used to ask my neighbours to visit Shafiya during the day, but now I don’t feel like bothering them,” Shakeela said.
Unprotected and Stigmatised
To add to Shakeela’s woes, are her engagements as a Covid-19 worker in the absence of adequate safety equipment. Despite ASHA’s being at a greater risk of contracting the virus, the government has not equipped them with proper protective gears.
“We have to go door to door, sometimes in containment zones as well but all we are given are few masks, which do not last for more than three days,” she alleged. “We mostly buy masks from our own pockets.”
Shakeela said that she has the constant fear of passing on the infection to her family members.
“We are totally exposed to the virus without any gloves and PPEs. I have a daughter with co-morbidity, and God forbid, if she contracts it, her health can deteriorate further,” she said.
The stigma associated with the virus has also made these health activists experience ostracisation in society.
“People are scared of the virus and also its carriers. They perceive us as the ones spreading the virus rather than curbing it,” said another ASHA worker, wishing to stay anonymous. “I have faced disdain from people a lot of times. They get into heated arguments with us and deny entry into their homes.”
For many days, Rehana Jan (name changed), has been visiting some households in Mohalla Noorbagh of Kulgam, to enquire about the health of home-quarantined Covid-19 patients and their families. As she completes her Covid-19 related tasks, she stops by the house of a pregnant woman to motivate her for institutional delivery. Ironically, Rehana advises her to take properly balanced diet and supplementary nutrition, but she herself has not eaten anything throughout the day.
“I leave early in the morning and return at around 4 pm, and in-between I don’t get time for lunch”, she said. “Skipping meals has become a norm now, I know it is badly affecting my health but I can’t help it”.
Akin to other ASHA workers, 36-year-old Rehana, has been tirelessly working at the forefront during the pandemic and acts as a bridge between the community and the health system.
“As soon as we get information about a positive patient from the health department, we have to set out to trace his contacts, ask them if they have any symptoms and also make them aware about taking the necessary precautions like isolation, using masks etc,” she said.
Back in 2002, when Rehana completed her graduation from a local college, her parents sent her to Delhi to earn a two-year diploma in Medical Lab technology. On returning, she voluntarily practiced as a laboratory technician in District Hospital Kulgam for some months and then decided to start her own medical lab.
“Initially, I used to carry out the common laboratory tests and then got some doctors for consultation too. Minor surgeries were also performed in the clinic,” Rehana said.
The clinic was quite a success for Rehana, until she gave birth to her first daughter.
“I got married in 2009 and after the birth of my daughter, I was diagnosed with postpartum haemorrhage. My health deteriorated and I had to close the lab.”
In 2011, Rehana filed an application in the health department for the position of ASHA and owing to her medical qualification and experience; she was readily accepted for the post.
Over the last 10 years, she has undergone a series of training and is considered one of the most hardworking health activists by her community and colleagues. “We do this work for our own people, they trust us,” Rehana said. “We have our issues with the authorities but that is not stopping us from performing our duties”.
Erratic Work Hours
According to the guidelines of the National Rural Health Mission (NRHM), an ASHA is supposed to have a flexible work schedule and her workload has been limited to putting in only about 2-3 hours per day, on about four days a week, except during some mobilization events and training programmes.
But in reality, the work hours of ASHAs often referred to as foot soldiers, are extended beyond the specified hours.
“Surveying is not an easy task. Sometimes we are required to visit more than 30 households in a day. We don’t even get time to breathe,” exhausted Rehana said. “In fact, we work 24×7. Our phones have to remain active always; I have assisted some deliveries past midnight as well.”
The inclusion of the Covid-19 related responsibilities has further added to their workload and also taken a hit on the usual incentive generating tasks.
“The work has intensified. We are not able to perform other activities such as prenatal and post-natal care, immunization etc,” Rehana said.
Many ASHAs have also complained of physical discomfort because of the laborious footwork.
“Back pain and numbness in feet is something that most of us experience every day,” Rehana said. We don’t even have time to consult doctors, despite ourselves being a part of the healthcare system”.
Doctors also believe that excessive walking can lead to certain joint and ligament problems. “Whenever a person works more than his capacity, it is definitely going to be detrimental for his health,” an orthopaedic working at a District Hospital said. “Covering long distances on foot and then managing other household duties as well, can possibly lead to more back and knee paints in females.”
There are other worries too. Unable to give time to their families, these working women often face challenges in their personal relationships. According to Rehana, many of her co-workers have complained of bitter fights with their in-laws, adding that they are looked down upon for not earning a handsome salary.
“Not every family understands. ASHA workers often have to face harsh reactions from in-laws who either are not happy with their long working hours or because their salaries are low,” said Rehana.“They are being asked to look after the household chores and quit the job, as it fetches them nothing.”
Echoing her thoughts, Shakeela said: “My husband also threatens me of divorce, for sometimes the food is not ready or his clothes are not washed in time. He feels my daughters are suffering because of my work.”
Surviving on Hope
For all the unrecognized and low-paid ASHAs, it is the hope that keeps them going – hope for acknowledgement, the hope of regularisation and hope to get increment.
“We struggle with our people, the system, and our own families. But no matter how bad it seems today, it will be a better tomorrow,” Rehana said while addressing a group of protesting ASHA workers in Kulgam. “In sha Allah,” they replied with one voice.
A Death Not Mourned
In the last week of May, Baramulla lost Khalida Begum, 36, an ASHA worker for more than a decade, to Covid19. A resident of Banpora in Sheeri, she died within 24 hours after developing the symptoms. Before her death, she had vaccinated almost 500 senior residents and helped almost all pregnant women in delivery during the pandemic.
Survived by two children, she was the only bread-winner of the family as her husband, Ghulam Nabi Dar, is ailing.
Interestingly, the ASHA workers are excluded from the list of the frontline workers and there is no incentive to them for their Covid19 word or a scheme for compensation if they died while fighting Covid19. This is a serious crisis that ASHA workers are facing, right now.
People know they are the ground zero backbone. “They are put to almost 24 hours’ of duty, without leave and asked to conduct surveys, report the cases, getting medical help to the infected, monitoring the patients, follow up with the recovered ones. Besides, they are put to vaccination duties for almost 8-9 hours a day,” Communist leader Yousuf Tarigami said in a statement. “It is most unfortunate that most of their families are denied the much-acclaimed compensation of Rs 50 lakhs. These poor employees are not being paid minimum wages nor are there any social security benefits. In the name of ‘honorarium’ or ‘incentive’, they are paid a pittance. The situation is so bad that even their regular monthly remuneration is pending for many months. The successive governments have totally neglected them.”
The government could extend certain benefits to them quickly like including them in the frontline workers and extending the insurance cover to them. There is no harm in invoking the minimum wages act so that they take a decent sum home.
In absence of these benefits, a huge ASHA population is in a perpetual nirasha state. Jammu and Kashmir has around 19903 ASHA workers spread across 20 districts, of them, 9362 in Jammu and 10541 in the Kashmir region. They lack any right that workers usually have. That does not mean they deserve to be exploited.