THE UNSUNG HEROINES AT THE FOREFRONT : THE ROLE PLAYED BY ASHA WORKERS IN ENCOUNTERING THE PANDEMIC IN KERALA

ABSTRACT
⁠The period of Covid 19, which is unprecedented in history with respect to high death tolls and spreading rates, has witnessed unique experiences of creative intervention and support in combating it. The involvement and commitment of ASHA workers, the forefront warriors in the health sector have been successful in providing care and support to those who live in fear of being affected and who are thwarted by its physical, sociological and psychological impact. The paper tries to analyse the role played by ASHA workers in Kerala during the pandemic times in fighting against it by curtailing the spread, completing the vaccination, serving the patients and minimising othering and stigmatization of the affected. It also tries to expose the challenges and constraints the ASHA workers are facing are and the need for giving them more acknowledgement and accolade.
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⁠Keywords : pandemic, ASHA workers, frontline warriors, intervention
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⁠Calamities always create collective trauma. They leave indelible marks of pain, suffering, loss and depression. But the timely and effective support and intervention of the fellow beings play a vital role in helping them survive such experiences. Throughout history, instances of immense and valuable support and intervention during pandemics have been seen in spite of all risks and perils.In the past, community engagement has proved its potential impact on people experiencing humanitarian crises especially during Ebola and Zika outbreaks. These creative interventions have exposed themselves as the best ways to respond to such traumatic experiences as they help in building trust, bringing solidarity, guidance, information and empathy. Their impact had gone even beyond the pandemic mitigation towards new normal by using community structures to come up with practical solutions. Community engagement had played a crucial role in the Ebola epidemic management. Under the Community-led Ebola Action (CLEA) approach, 2,500 volunteers were trained during the Ebola outbreak in 2014. Structured tools and strategies were used by the volunteers to evoke community response around triggering events. Body mapping to identify key symptoms of Ebola, danger discussion and survivor stories were some of the techniques adopted. Representatives from different sections of the community were acquainted with these and they were directed towards arriving at their own plans of action through collective deliberation in order to prevent disease transmission, promote self-ownership and community agency.
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⁠In times of distress, hardship and illness, community support is very important and is more essential, especially when isolation and distancing are imposed as necessity. Covid 19 has brought in a singular and complex situation where we have to keep physical distance, at the same time take care for other members of our family and community. It has created unnecessary paranoia and has changed the structure and relationships within and between communities. Here comes the need for the right kind of social intervention which is capable of mitigating the epidemic as well as bringing back the normalcy and the desired alleviation of the resultant problems like, poverty, hunger, economic depression, joblessness etc.The experience the state of Kerala had in this regard during the outbreak of the Nipah virus has been very useful during the outbreak of Covid. Many groups are at the forefront responding to the need, like octors' Associations, Nurses' Associations, volunteers, local governing body members, NGOs, frontline workers, local self-help groups and so forth. But the conspicuous role played by ASHA workersin these varied community engagement initiatives deserves much attention and acknowledgement.
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⁠Women are the worst affected group during the pandemics; but they haveshown the power to make the best contribution in hard times. In the case of Covid too, women have proved their prowess to be the potential warriors for combating it as well as for helping the victims and those who are most vulnerable. The most remarkable among such women fighters are ASHA workers, (Accredited Social Health Activists) the voluntary health workers operating under the National Health Mission of the Union Government.They are engaged in manifold services and interventions crucial to public health and welfare like antenatal and postnatal care, immunisation and so on. “ASHAs are a volunteer cadre of over a million women health workers who serve as a crucial interface between India's community and public health delivery, providing maternal and child health care, immunisation among other services and supplying the government with critical on-ground health data” (Prasad and Arathi).They provide substantial support to the Public Health departments of various states along with the permanent employees by utilizing their intimacy and connections with the local community. As pointed out by Farah N Fathima, an ASHA is usually a resident in the community and who is trained, deployed, and supported to function in her own village to improve the health status of the people through securing their access to healthcare services. She states: “Her job responsibilities are three-fold, including the role of a linkworker (facilitating access to healthcare facilities and accompanying women and children), that of a community health worker (depot-holder for selected essential medicines and responsible for treatment of minor ailments), and of a health activist (creating health awareness and mobilizing the community for change in health status)” (2015).
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⁠Other than the usual services, they also provide special support to the states in the prevention of contagious deceases too. ASHAs in Kerala have lately undertaken other responsibilities in response to the state's decentralised health care system. Their interventions help the government in managing non-communicable diseases by communicating and monitoring required lifestyle changes, reduction of substance abuse and adherence to treatment by patients, and they administer palliative care in the state's cancer-care programme too. The official website of Kerala Government, Arogyakeralam.gov.in.states the role of ASHA Workers :“ASHAs will act as a link between the community and health care services and ensure that the primary health care services are accessed by the rural poor. Considering the peculiar Health scenario in Kerala the role of ASHAs has been extended to other fields like Prevention & Control of Communicable diseases, Identification & Control of NCD's, Palliative care and Community based Mental Health Programme.” During the Covid times, they serve as the frontline warriors by assisting in planning local-level actions in collaboration with local bodies like contact tracing, giving awareness, supporting the sick and those in quarantine, providing vaccine etc. These efforts have helped to minimize the othering and stigmatisation in communities and created an ethos of cooperation and altruistic sensibility.Along with the technology-based surveillance systems and official initiatives, ASHA workers use traditional surveillance mechanisms through their intimate connection with the local residents. They even give confidence and consolation through telephonic conversations to those who are covid positive and those who are in quarantine. They also inform the neighbours of those on home quarantine and provide food and medicines to the quarantined and other members in the locality.
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⁠Kerala was the state to report India's first Covid-19 case on 30 January 2020 and still contines to be the worst affected state by Covid. But it manages to effectively battle with the pandemic mainly due to the community based intervention and support provided by the ASHA workers. In the article , “ASHAs Within the 'Kerala Model' Lead Covid-19 Response, Get Little in Return” published in Deccan Herald, Pallavi Prasad and Arathi P.M observe: “ Central to Kerala's public health response are more than 28,000 women ASHAs who are at the forefront of the resistance against Covid-19. Kerala's success, in large part, can be credited to the ASHAs' meticulous pre-Covid-19 data collection of every household, their intricate database of every person who moved out of Kerala for work and their health indicators. This enabled the state to develop a rapid 'trace-testisolate-support' strategy.” They point out how ASHAs undertook activities crucial to the pandemic response–tracking and tracing people with travel history and Covid-19 symptoms, reporting them to public health centres, arranging for their testing and educating the public –despite challenging conditions with minimal protection, inadequate support from higher-level healthcare staff and rising hostility within the communities they serve.
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⁠But it is to be noted that this sorority of women who give committed service to the public health scenario largely remain unacknowledged and underprivileged. They also work under a lot of constraints and challenges. ASHAs across India are not formally included as employees of the health department but continue as contingent volunteers under the National Health Mission. Their financial gain come only from the incentive received from the UnionGovernment and the honorarium that is deployed through the state government.Financial security is only a dream for them as they are not given monthly salary, travel allowance, health insurance and provident fund from the Government. They are managing with activity based incentives, which are not sufficient for fulfilling their needs ( SwathiShet).
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⁠Though they are troubled by these diverse issues along with social insecurity, lack of self-confidence and increasing work load, they remain pleasant and satisfied, “They juggle household tasks and healthcare activities, and despite being inadequately paid, they still find deep satisfaction in their work.” (Mascarenha). This attitude is instilled by their passion and desire for social service. It is the duty of the society and the Government to ensure that they are duly rewarded by providing financial security and social recognition. They need to be merged with the mainstream systems and avenues of the public health scenario. That is the responsibility of a society who receive their valuable services and interventions.
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⁠References
⁠· Fathima, Farah N, et al. (2015) “Assessment of 'accredited social health activists'-a national community health volunteer scheme in Karnataka State, India.” Journal of Health, Population, and Nutrition. Vol. 33, no.1, 2015, pp. 137-45. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4438657

· Prasad, Pallavi and Arathi P.M(2020) “ASHAs Within the 'Kerala Model' Lead Covid-19 Response, Get Little in Return.” Deccan Herald. 11 May 2020. https://www.deccanherald.com/ national/south/advance-planning-effectiveexecution- how-kerala-is-fighting-its-battleagainstcovid-19-836264.html

· Mascarenhas, Anuradha (2021) “ASHAs Struggle to Balance Work, Home Despite Job Satisfaction.” The Indian Express. 11 February 2021. https://indianexpress.com/article/india/studyreveals--ashas-struggle-to-balance-work-homedespite-job-satisfaction-7184561/

· Shet, Swathi, et al. (2017) “A study on assessment of ASHA's work profile in the context of UdupiTaluk, Karnataka, India.” Clinical Epidemiology and Global Health, Volume 6, Issue 3, 2018,pp. 143-147. https://doi.org/10.1016/j.cegh.2017.08.004.