The foot soldiers of Kerala’s Covid-19 battle, 26,000 women who won’t overlook any detail

“You never know what comes handy when,” she says.

On other days, she can be found in the local corporation hall taking nutritional classes for expecting mothers or lecturing on family planning among newly-weds.

But these are not normal days. Over the past three months, during the course of which a frightening pandemic has gripped Kerala and the rest of the world, Latha and nearly 26,000 ASHAs across the state have taken on braver, far more challenging roles. They have become the eyes and ears of the government on the ground, constantly flitting through their jurisdictional areas like a detective, scouring for people with infections and keeping a stern vigil on their quarantine. If someone coughs or sneezes, hers is the phone that rings first. If someone entered the ward after travelling from another district, she would be the first to know.

“This is my 10th year as an ASHA worker and when you spend so much time among the community, people automatically become close to you. When a woman becomes pregnant in my ward, sometimes I’m the first to know before she even tells her family,” jokes Latha.

Kerala’s health department is essentially banking on such interpersonal connections between ASHAs and the communities around them to help cast its surveillance net and keep close track of those who can potentially get infected with the coronavirus which has killed nearly 2 lakh people across the world. In mid-January, when news of a new virus infecting thousands in Wuhan in China spilled out, Kerala sat up, alarmed. A few hundred of its medical students stayed in Wuhan and if they were to return, the state had to take precautionary measures. Within days, a control room was set up in Thiruvananthapuram to coordinate measures and rapid response teams (RRTs) formed at the panchayat level. A key participant of such teams were the ASHAs.

“Only an ASHA will have the complete health profile of the ward designated to her. She has to know every minute detail. The entire public health system is dependent on us because we have the data. That’s why we are integral,” said Beena, an ASHA in Paravur block panchayat on the northern fringes of Ernakulam district.

Over the next few weeks as the novel coronavirus spread to Europe, the United States and the Middle East, where a large Malayali expatriate population lives and works, ASHAs in Kerala on a parallel scale foraged through the state’s nooks and corners to look for signs of the infection among the returnees. By the time a national lockdown was put into place in mid-March, thousands of people had poured into the state from around the world, scattered across its densely-populated neighbourhoods.

But thanks to the ASHAs, now there was real, quantifiable data on the foreign returnees in the hands of the health department. Every day, hours before Chief Minister Pinarayi Vijayan addressed the press in Thiruvananthapuram, ASHAs called up their higher-ups to pass on reports on the people in their respective wards. These reports, later tabulated at state-level, formed the crux of the CM’s presser. It was a perfect chain of decentralised data-gathering and decision making.

Kerala’s health department is banking on interpersonal connections between ASHAs and communities around them to help cast keep track of potential Covid-19 cases. (Arranged/Express Photo)

“/Krityamaya vivaram kittanam ennulathu namukku oru vashi pole aayirunnu/ (We were persistent that we had to get the correct information),” echoed PP Prema, state president of the ASHA workers union affiliated to the CITU, the trade-union wing of the CPI(M). “There was no room for error. Strict instructions had been issued to all workers that not a single piece of incorrect information should be passed above. We had to be very careful.”

For the record, this was no mean task. The ASHAs spent countless hours interviewing and often grilling people who had come from abroad, and then cross-verifying the information from other sources. District administrations, while preparing flow maps of the travel routes of an infected person, often relied on the reports of the local ASHA. Many of the ASHAs that the /Indian Express/ spoke to revealed that during the initial weeks of the lockdown, they had no access to masks and gloves. As the public remained in their homes and bureaucrats safely ensconced inside offices, grassroot workers like ASHAs and junior health inspectors manned the neighbourhoods with towels covering their faces.

But the experience is not new to ASHAs. During the Nipah virus crisis in Kozhikode in 2018, when 18 people succumbed to the infection, Prema recalled a mental dilemma she had to face. An ASHA was deputed to go to the home of a person who had died of Nipah and burn his clothes.

“She called me up to say she was ready to do it even though the risks were high. But she was worried about her two daughters. She asked me to take care of her children if something happened to her. Honestly, if I tell you, I couldn’t sleep for the next 20 days, worried about her. But thankfully, she did her job and nothing untoward happened. It’s not an understatement when I say an ASHA puts her life on the line to do her job,” said Prema.

During the ongoing Covid-19 surveillance too, the work of ASHAs has not been without jitters. For one, getting information hasn’t always been easy. Some of them turned hostile when asked about their travel history and wilfully violated quarantine guidelines set by the health department. Such errant persons were reported to higher-ups in the health department and if the matter isn’t sorted there either, the police would be called in.

Sajitha, an ASHA worker in Kozhikode district’s Koyilandy, described over a phone call how she had to face backlash from a bunch of men who were violating the lockdown. “This was around the time the prime minister had announced the first phase of the lockdown. My ward is a hilly, rural area and quite far from the nearest town. Every day, I would see this bunch of young men, all in their 20s, sitting and playing on their smartphones on a bench by the side of the road. There were at least 15 of them. I told them repeatedly to stay within their homes and follow the lockdown measures. But they didn’t listen to me,” she said.

“So I escalated it to the junior health inspector and the police. Every time they saw a police jeep, they would scatter. So one day, in jest, I asked them why they ran every time they saw the police. It was meant to be a joke, but I don’t think they liked it. A couple of days later, they vandalised my daughter’s scooter at night when we were asleep. The mirror was broken and the tyres were punctured.”

Sajitha said she was ‘deeply shaken’ by the incident as it was her first harrowing experience in over a decade of work as an ASHA. “I don’t have a son so I always looked upon them as my own sons. I was sad that nobody stood up for me when this happened. My husband is abroad and I have two young daughters. We are isolated, but that’s okay. We have to continue living here.”

At 48, with a leg injury that needs immediate surgery, Sajitha cannot walk too far. Her daughter gives her a ride on the scooter when she’s too tired. But despite the physical stress and her own health problems, she doesn’t want to hang up her shoes yet.

“It gives me peace of mind,” she said, smiling. “When I moved here six years ago, the place was crawling with dengue and chikungunya cases. But now, for the past two years, there are no outbreaks. There’s change.”

In fact, even as they continue to monitor the Covid situation at the local level and send daily reports, a new challenge has risen on the horizon: dengue. Circulars have gone out from the top echelons of the health department to all ASHAs to begin vector studies at the ward level to prevent an outbreak. Wells have to be chlorinated and homes disinfected. With the annual southwest monsoon just a month away, a dengue outbreak can pulverise the health machinery.

Kerala’s ruling Left government has been largely sympathetic to the cause of the ASHAs, substantially hiking their performance-based honorarium from Rs 1,000 to Rs 5,000. (Arranged/Express Photo)

“I’m just back home after chlorinating a few wells in the neighbourhood. After this, I have to distribute some masks and then drop off medicines at an elderly person’s home. The truth is that a majority of the ASHA workers in the state are today overburdened with work. There’s not a moment’s peace in our lives,” said Lissie, the Ernakulam district secretary of the ASHA workers union.

Like Sajitha, Lissie’s jurisdiction falls within a hilly, sparsely-populated area on the eastern fringes of Ernakulam where homes are sometimes separated by a few hundred metres. At a time like this when a public health emergency is underway, there are too many tasks at hand and very less time. To cover more distance, she sometimes travels by rickshaws which charge hefty fares.

“We don’t get any kind of travel incentives. There are ample funds available with panchayats, but they won’t spend them. They won’t even release vehicles if we have to go somewhere urgent. All we earn is the performance-based honorarium of Rs 5,000. But even that is at the mercy of the junior public health nurse or the junior health inspector. If they are kind to us, we will get the honorarium,” she said.

Kerala’s ruling Left government, which assumed power in 2016, has been largely sympathetic to the cause of the ASHAs, substantially hiking their performance-based honorarium from Rs 1,000 to Rs 5,000. The chief minister also announced an extra incentive of Rs 1,000 to all ASHAs, hailing them for their exemplary work on Covid-19.

Latha, who ditched a job at an insurance firm to become an ASHA in 2010, said there’s a special kind of happiness in doing service-oriented work. The monthly honorarium is barely enough to make ends meet in her family, but the validation from the people motivates her to go on.

“The other day, I was walking with a towel across my face. Seeing me without a mask, a woman who’s a cancer patient in my ward, asked why I didn’t have one. I said I couldn’t get hold of one. The next day, despite her physical ailments, she stitched a few masks just for me. I was speechless. This is what we live for, right?” she smiled.

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