Sanket Jain

Sangeeta Menon

Editor

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When flood water started entering her
home in July 2021, Shubhangi Kamble fled leaving her belongings behind. On her
way out, though, she quickly grabbed two notebooks. 

Over the weeks and months ahead, these
two books, 172 pages each, would help her save many lives. 

For that was the time when her village, Arjunwad, in Maharashtra’s Kolhapur district, was already
dealing with another calamity – a rapid rise in Covid-19 cases. And neatly
written on the pages of Shubhangi’s notebooks was all the information related
to the coronavirus cases in the village, including contact numbers, address, details of other members in the family, their
medical history, health records, and so on.

“Covid reports [of RT-PCR tests
conducted in the village] would first come to me,” says the 33-year-old
Accredited Social Health Activist (ASHA), one of a million women community
health care workers appointed under India’s National Rural Health Mission of
2005. Her notes helped her track down a Covid-positive villager who had
been moved to a flood relief camp in Shirol taluka, exposing at least 5,000
other people to the virus.

“Because of the floods, many people’s phones were switched off or out of network
coverage,” she says. Shubhangi, who had moved to her mother’s house in Terwad, 15 kilometres away, immediately
searched her handwritten records and found phone numbers of some others at the
camp. “I somehow managed to contact the patient.”

She also arranged a bed at a Covid centre set up in the
nearby Agar village and the patient was swiftly moved there. “Had I not taken the notebook, thousands
of people would have been infected,” she says. 

That was not the first time Shubhangi
had averted a major crisis for her village or put her duty above herself. After
the 2019 floods (in August), she reported at work even before she could tend to her own
damaged mud house. “I was busy surveying the damage of the entire village as per the
village panchayat’s orders,” she says.

For over three months after that, she
went around the village talking to flood survivors and seeing devastation
everywhere. What she saw and heard disturbed her immensely; she started
experiencing anxiety and stress while noting down the losses incurred by the
over 1,100 households she surveyed.

“I was neglecting my mental health,” she
says. “But what option did I have?”

Even before she had recovered from the
trauma caused by the floods that year, she was at the forefront of Covid relief in 2020. And
even as the pandemic raged, she was back to helping those affected by floods in July 2021. “Floods and Covid together meant a
disaster much larger than we could ever imagine,” says Shubhangi. 

The continued neglect of her own mental
health eventually began to manifest in various ways.In April 2022, she was diagnosed with pneumonia and
moderate anaemia. “I was feverish for eight days but, because of work, I
kept ignoring the symptoms,” she says. Her haemoglobin fell to 7.9, well below
the ideal level for women (12-16 grams per deciliter
of blood), and she had to
be hospitalised.

Two months on, just as she was
recovering, her village witnessed heavy rains – and Shubhangi once again
started experiencing stress seeing the rapid rise in water levels. “Once, we would eagerly await the rains,
but now with every rainfall we fear another flood,” she says. “This year in
August, the water was rising so quickly that I couldn’t sleep for several days.” [Also read: <a href="https://ruralindiaonline.org/en/articles/in-kolhapur-athletes-get-that-sinking-feeling/">In Kolhapur, athletes get that sinking feeling</a>]Despite continued treatment, Shubhangi’s haemoglobin
level remains low; she also complains of dizziness and fatigue. But there is no
rest or healing in sight. “As ASHAs, we are supposed to become a support system
when we ourselves are completely devastated,” she says.

ASHA worker Chhaya Kamble, 38, from
Shirol’s Ganeshwadi village, remembers the 2021 floods in great detail. “The rescue boat was sailing above our
house,” she says.

Like Shubhangi, Chhaya too was back at
work as soon as the water started receding; her home would have to wait. “All
of us [the six ASHA workers of Ganweshwadi] first went to the sub-centre,” she says. Since the floods had
damaged the building, they created a makeshift sub-centre at a resident’s house.

“Every day, several people affected by
pneumonia, cholera, typhoid, skin diseases, fever, and more would come [to the
sub-centre].” This duty lasted a whole month, without even a day off.

“Seeing everyone in tears does affect
you,” says Chhaya. “Unfortunately, there is no mental health care facility for
us. So, how do we heal?” As it turns out, she did not. 

Her stress levels continued to rise and
she soon began experiencing shortness of breath. “I kept ignoring it thinking
it must be because of the workload.” Within a few months Chhaya was diagnosed
with asthma. “The doctor said it was because of the tremendous stress,” she says;
there are enough <a href="https://erj.ersjournals.com/content/37/6/1360">studies</a> that establish the link between stress
and asthma.

While medicines are helping Chhaya, she
cannot stop worrying about the rapid changes in the climate. During the
heatwave of March-April this year, for instance, she started experiencing spells of
dizziness and breathlessness.

&quot;It was the toughest time to be on duty.
I felt like my skin was burning,” she recalls. Research has found that high temperatures can affect <a href="https://link.springer.com/article/10.1007/s40279-016-0657-z">cognitive functioning</a>, even leading to a rise in <a href="https://www.nature.com/articles/s41558-018-0222-x?source=post_page---------------------------">suicide rate</a>, <a href="https://link.springer.com/article/10.1007/s40641-019-00121-2">violence and aggression</a>. 

Many other ASHA workers report similar
symptoms as Chhaya. “This is not odd. These are symptoms of seasonal affective
disorder [SAD],” says Kolhapur-based clinical psychologist Shalmali
Ranmale-Kakade. SAD is a form
of depression triggered by a change in season. While symptoms are more commonly
associated with winters in higher latitude countries, there is increased awareness about the disorder affecting people in <a href="https://pubmed.ncbi.nlm.nih.gov/9609679/">tropical countries</a> like India too.

“As the climate changes, I start
feeling anxious; I feel dizzy. Aata mala aajibat sahan hoina jhalay [I
can’t take this anymore],” says Shubhangi. “Almost every flood-affected ASHA is
experiencing some form of stress, which is now leading to chronic illnesses.
Yet, the government does not help us despite saving so many people.” 

Not that health authorities don’t
acknowledge the problem. The question is whether their response is adequate, or
even correct.

Dr. Prasad Datar, Taluka Health Officer of the
nearby flood-affected Hatkanangle taluka, says health care workers in the region
are “overworked and stressed” since the floods and Covid. “To help address these
concerns, we organise cultural programmes for ASHA workers annually,” he
adds.

However, ASHA union leader Netradipa
Patil, based in Kolhapur’s Shirol taluka, believes these programmes are not helping. “When I
voiced the mental health concerns to the authorities, they dismissed it saying
we need to learn to deal with such situations,” she adds.

Ranmale-Kakade says ASHA workers need
therapy and counselling so they are able to cope with the persistent stress.
“The helping hand, too, needs help,” she says. “Unfortunately, this doesn’t happen in our society.” Moreover, she
adds, many frontline health care workers are so much in ‘helping mode’ that they often don’t identify their own burnout, frustration and emotional burden. 

Dealing with recurring stressors, such
as the rapidly changing local climatic patterns, requires increased intensity
and frequency of interventions, she adds.

The changing climate patterns have more
than one role to play in the declining mental health of ASHA workers in
Kolhapur.

Despite the immense load on them – each
ASHA handles over 70 health care tasks for 1,000 people in a village, including
ensuring safer pregnancies and universal immunisation – these health workers
remain poorly paid and exploited.Netradipa points out that ASHAs in
Maharashtra are paid a meagre Rs. 3,500-5,000 per month, that too with a delay of
at least three months. “Even today, we are considered volunteers, which denies
us minimum wages and other benefits,” she elaborates. ASHA workers receive what
the government calls a ‘performance-based incentive,’ which means that they are paid upon the <a href="http://164.100.24.220/loksabhaquestions/annex/176/AU892.pdf">completion of certain tasks</a> in their community. There is no fixed honorarium and the pay varies from one state to
another.Many ASHA workers, therefore, cannot
survive solely on their income from taking care of the community’s health care
needs. Shubhangi, for instance, would double up as an agricultural labourer to
make ends meet. “After the 2019 and 2021 floods, I
could not find work for three months as the fields were destroyed,” she says.
“With the changing climate, the rains have become unpredictable. Even if it
rains for some time, it destroys everything, including our hopes of getting
farm work.” In July 2021, heavy rain and floods affected 4.43 lakh hectares of crop area across 24 districts of Maharashtra, including Kolhapur. Since 2019, recurring floods and destruction to property as well as loss of agricultural work have forced Shubhangi to seek small, high-interest loans totalling Rs. 100,000 from different moneylenders. She even had to pawn her gold, and shift to a 10x15 feet tin shanty as she could not afford to rebuild the old house.“Both in 2019 and 2021, floodwater
entered the house in less than 30 hours. We could save nothing,” says her
husband, Sanjay, 37, who has now started working as a mason because there is
not enough work to be found as an agricultural labourer.

Despite her own losses and suffering,
Shubhangi found herself spending more time attending to the relentless demands
of her work as an ASHA.

Along with surveying the losses caused
by the floods, ASHAs were tasked with disinfecting drinking water sources to
prevent the spread of water-borne diseases. Many of their tasks are not even
paid for, says Netradipa. “For doing all this post-flood relief work, which caused
us so many mental issues, we were paid nothing. It’s all free labour.” 

“We had to visit every house and note
down if anyone had any symptoms of water-borne or vector-borne diseases,” says
Shubhangi. “ASHAs saved several lives by ensuring timely treatment.”

Yet, when she herself fell ill in April
this year, she received little support from the system. “Despite being a public
health care worker, I had to seek treatment in a private hospital and spend Rs.
22,000 because the public hospital was
only prescribing medicines whereas I needed to be hospitalised immediately,”
she says. Although she receives free folic acid and iron supplements from the
public sub-centre, she continues to spend Rs. 500 on additional medicines every
month. Chhaya, who earns around Rs. 4,000 a
month as an ASHA worker, spends around Rs. 800 on medicines, which she can ill
afford. “In the end, we have accepted the fact that we are social workers. That’s probably why we have to suffer so
much,” she says.In 2022, the World Health Organisation (WHO) honoured ASHA workers with the <a href="https://www.who.int/india/india-asha-workers">Global Health Leaders Award</a> for making health care accessible by
connecting remote communities to the public health system. “We are all proud of this,”
says Chhaya, “but whenever we ask our seniors about the delayed and meagre
payment, they reply that we are doing incredible service for humanity –
‘Payment changla nahi milat, pan tumhala punya milte [You may not
be paid well, but earn people&#39;s blessings),’ they tell us.”

A <a href="https://www.who.int/publications/i/item/9789240045125">WHO policy brief</a>, however, draws attention to the important issue of the
impact of climate change on the mental health of these frontline workers: “The
development of mental health conditions, including depressive, anxiety and
stress-related conditions, has been reported following extreme weather events.”Climate events, combined with
deteriorating working conditions and apathy towards their situation, are taking
a toll on the physical and mental health of ASHAs, says Netradipa. “While surveying in the heatwaves this
year, many of us reported skin irritation, burning sensation and fatigue,” she
says. “We
were not given any protective
gear.” Roxy Koll, a climate scientist at
Pune’s Indian Institute of Tropical Meteorology (IITM) and a contributor to the
United Nations Intergovernmental Panel on Climate Change report,
emphasises the need for a ‘climate action plan’ that clearly mentions the
periods of the day when heatwaves and extreme events are much stronger. “We
have climate projections for the next several years to decades. So, it is
possible to identify those regions and the timings of the day when workers
should not be out in the sun,” he says. “This is not a big task. The data is
already there.” In the absence of any official policy or effort in
this direction, ASHA workers are left to devise their own ways to deal with the
situation. Shubhangi thus starts her day by checking the weather forecast. “I
can’t abandon my duty; I can at least try preparing myself
to face the day’s weather,” she says.

This story is part of a series supported by Internews’ Earth 
Journalism Network through an independent journalism grant to the 
reporter.

In Kolhapur, ASHAs tell a SAD story

کولہاپور میں آشا کارکنوں کی ’اداس‘ کہانی

అనూహ్యమైన వాతావరణ మార్పుల వలన మానసిక ఆరోగ్యాన్ని కోల్పోతున్న కొల్హాపూర్‌ ఆశాల విషాద గాథ

கொல்ஹாப்பூரில் சுகாதாரச் செயற்பாட்டாளர் சொல்லும் துயரக் கதை

ਕੋਲ੍ਹਾਪੁਰ ਦੀਆਂ ਆਸ਼ਾ ਵਰਕਰ: ਸਾਂਝੀ ਪਰ ਉਦਾਸ ਕਹਾਣੀ

କୋହ୍ଲାପୁରରେ ଆଶା କର୍ମୀଙ୍କ ଦୁଃଖ କାହାଣୀ

കോലാപുരിൽ, ആശാപ്രവർത്തകർ ഒരു ദു:ഖകഥ പറയുന്നു

ಕೊಲ್ಲಾಪುರದ ಆಶಾ ಕಾರ್ಯಕರ್ತರ ಮಾನಸಿಕ ಆರೋಗ್ಯದಲ್ಲಿ ಏರುಪೇರು

कोल्हापुर: आशा कार्यकर्ताओं की ‘उदास’ कहानी

કોલ્હાપુરમાં આશા કાર્યકરોના મનની બદલાતી ઋતુઓની વારતા

कोल्हापुर: मितानिन मन के दिमागी सेहत मं बदलत मऊसम के मार

জলবায়ু পরিবর্তন ও মানসিক উদ্বেগে জেরবার কোলাপুরের আশাকর্মীরা

ক’লহাপুৰত আশাকৰ্মীৰ মানসিক স্বাস্থ্যৰ অৱনতি

कोल्हापुरात आशांच्या मनःस्वास्थ्यातले चढउतार

Shirol taluka

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In Kolhapur, ASHAs tell a SAD story

All is not well with the mental health of women health workers in rural Maharashtra as they grapple with the adverse effects of climate change and deteriorating working conditions

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