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 in India, 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 kilometers 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 center 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 (council'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 anemia. “I was feverish for eight days but, because of work, I kept ignoring the symptoms,” she says. Her hemoglobin fell to 7.9, well below the ideal level for women (12-16 grams per deciliter of blood), and she had to be hospitalized.
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.”
Despite continued treatment, Shubhangi’s hemoglobin 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-center,” she says. Since the floods had damaged the building, they created a makeshift sub-center at a resident’s house.
“Every day, several people affected by pneumonia, cholera, typhoid, skin diseases, fever, and more would come (to the sub-center).” 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 studies 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 and April this year, for instance, she started experiencing spells of dizziness and breathlessness.
"It was the toughest time to be on duty. I felt like my skin was burning,” she recalls.
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 tropical countries 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 counseling 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 immunization—these health workers remain poorly paid and exploited.
Netradipa points out that ASHAs in Maharashtra are paid a meagre 3,500 to 5,000 rupees 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 completion of certain tasks 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 laborer 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 443,000 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 totaling 100,000 rupees from different moneylenders. She even had to pawn her gold, and shift to a 10-by-15-foot 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 laborer.
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 waterborne 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 labor.”
“We had to visit every house and note down if anyone had any symptoms of waterborne 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 22,000 rupees because the public hospital was only prescribing medicines whereas I needed to be hospitalized immediately,” she says. Although she receives free folic acid and iron supplements from the public sub-center, she continues to spend 500 rupees on additional medicines every month.
Chhaya, who earns around 4,000 rupees per month as an ASHA worker, spends around 800 rupees 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 Global Health Leaders Award 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 meager 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's blessings),' they tell us.”
A WHO policy brief , 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, emphasizes 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 was produced with support from Internews’ Earth Journalism Network. It was first published on November 25, 2022 in People's Archive of Rural India and has been edited for length and clarity.
Banner image: A combination of floods, heatwaves, the COVID-19 pandemic, and more have put enormous strain on health workers in Maharashtra / Credit: Sanket Jain.