Kolhapur, Maharashtra, India—Every night for three months in 2020, Kalpana Kamble, a community health care worker in India’s Maharashtra state, waited nervously for her phone to buzz. “These were the scariest notifications,” she told me. At 10 pm, the district health department would send her a PDF file with Covid test results for her region. “Already our village lacks adequate health care facilities,” Kamble said. “A Covid-positive case meant a community transmission was inevitable, because rarely people in the village followed Covid protocols, nor did they trust the Covid report.”

Kamble would then scroll through the list on her budget smartphone, looking for her village, Nerli. If someone in Nerli tested positive, Kamble, 47, would immediately head to the person’s house and complete a checklist of more than 10 tasks. First, she would monitor the patient’s oxygen and temperature levels. Then, depending upon the severity of symptoms, she would either suggest home quarantine or arrange for the person to travel to the nearest Covid facility 20 kilometers away.

Next, she would ensure that the Covid patient’s primary contacts completed 14 days of self-isolation. If she identified any contact who she thought might have Covid, she sent their names to her supervisors. This would take roughly three hours. Kamble then had to take the oxygen and temperature of every self-isolated patient three times a day and submit these handwritten records. “This duty was stressful because the patients wouldn’t cooperate with us, and many times even turned us away when we went to inquire about their health,” Kamble said. “But we couldn’t abandon this duty, otherwise the virus would have devastated everyone.” She did this more than 500 times in three months.

Kamble is an Accredited Social Health Activist (ASHA), a community health care worker employed under India’s National Rural Health Mission. The government hires one ASHA for every 1,000 citizens, which means there are over a million ASHAs—an all-female cadre of community workers unique to India. ASHAs are the first point of medical contact for the most vulnerable and isolated sections of society.

India has just 810 district hospitals for 833 million people living in rural areas. Many villagers must trek steep patches and hills to reach a public health care facility. As Dr. Madhuri Panhalkar, a community health officer, told me, “ASHAs know every community member and their medical history. Many people survived the pandemic only because of ASHA surveys and timely intervention that made our task of dealing with the patients much easier.”

In March 2020, as the coronavirus started spreading worldwide, India’s health ministry tasked ASHAs with containing local transmission. This Covid responsibility was in addition to more than 70 health care duties that ASHAs already perform, such as providing pre- and postnatal care, counseling women on birth preparedness, making the community aware of hygienic health practices, and maintaining the health records of every community member. ASHA workers helped slash India’s maternal mortality rate from 254 deaths per 100,000 live births in 2006 to 103 by 2019.

“The government relies on our field work,” Kamble said. “It is only ASHAs who help people immediately with primary health care since we are from the same community.… If we stop working, who will handle the medical emergency cases in the village?”

In April 2020, the government announced that it would pay ASHAs 33 rupees (42 cents) a day as a base rate. The government does not consider ASHAs full-time workers, despite their long hours. ASHAs are legally considered volunteers, but the government keeps increasing their workload.

In Maharashtra—the state with the most reported Covid-19—ASHAs earn an average monthly income of between $44 and $64 with performance-based incentives. But Maya Patil, an activist ASHA from Kolhapur’s Khutwad village, emphasized that “many ASHAs aren’t even paid this.”

ASHAs reported that the Rural Health Mission often paid late, leaving many unable to make rent or afford their own health care. Netradipa Patil, a union leader representing more than 3,000 ASHAs from Maharashtra’s Kolhapur district, said that at the height of the pandemic, many ASHAs didn’t receive money for three months.

As a result, many ASHAs took out loans from private money lenders at exorbitant interest rates and sold their land and jewelry to make ends meet. “Many ASHAs weren’t even given masks, PPE kits, and hand sanitizers for this dangerous Covid duty,” which only added to their expenses, Patil told me.

This was especially galling given their dangerous, back-breaking work. In May 2021, when India was reporting 414,000 Covid cases a day, India didn’t have enough testing facilities, and the country’s health infrastructure was overburdened. “If someone was Covid positive, we only got to know after five days,” Kamble said. That meant the person could be a virus carrier, making community transmission inevitable.

In many parts of rural India, villagers ostracized Covid-positive patients. “It was so bad that many weren’t even allowed to step out of their houses despite testing negative or completing quarantine,” she remembered. So instead of informing doctors, many people started taking paracetamol or consulted quacks. “Many threatened and even abused ASHAs” for reporting this, Kamble told me.

The burden of 12 to 15 hours of Covid duty every day and the rapid increase in deaths affected Kamble. She began to experience exhaustion, restlessness, and shortness of breath. After months of medical tests, she was diagnosed with congestive heart failure, a medical condition in which the heart muscle doesn’t pump enough blood. “The doctor says my heart is only 15 percent functional, and it happened because of the work stress,” she said.

“My medicines cost me over Rs 10,000 [$127] every month,” Kamble said. When she ran out of money, she sold her half-acre of farmland. Unfortunately, her doctor informed her that the treatment would continue for another 24 months, which will cost more than $3,000. As an ASHA, it will take her about five years to earn that money.

During the pandemic, India’s poor became poorer. One study found that Covid-19 is driving an additional 150 to 199 million people in India into poverty. The majority of these people are from rural areas, and women are feeling the brunt of this. ASHA leader Patil said, “We found several cases where a husband or family member beat up an ASHA or even threw her outside the house, because she couldn’t get paid on time.”

ASHA Maya Patil counsels a new mother.(Sanket Jain)

Since Covid hit India, many ASHAs have been diagnosed with chronic illnesses. Patil told me, “Many villagers abused ASHAs physically and mentally for doing their jobs, especially while surveying the communities to prevent community transmission.”

She said that there is little security or legal protection for ASHAs. Patil tried filing cases against anyone who assaulted or threatened ASHAs in Maharashtra, but local police would often ignore her. She then started asking them to file a report mentioning the offense, date, time, and other important details in the police station, so there’d at least be a record of the claim.

ASHA supervisor Shobha Patil, who manages 20 to 25 ASHAs in Maharashtra, witnessed many such instances of abuse. And within 16 months of being on Covid duty herself, she was diagnosed with diabetes. She also tested positive for Covid in September 2021 and had to seek treatment in a private hospital, because the public facilities were full. “Even public health care workers like me couldn’t get treatment in the government hospital. This is how badly we were treated,” she said. Today, Shobha Patil worries constantly about her medical debt and the increasing work pressure. Netradipa Patil told me, “Many ASHAs had neither access to public medical treatment nor to insurance.”

One such case was of ASHA Rupali Chavan (a pseudonym to protect her safety). Rupali told me her pay was delayed by five months. “Every day after coming from Covid duty late in the evening, the first question my in-laws and husband asked is when will I get paid,” she said. “After a few days, they were so livid that they first beat me up and immediately threw me outside the house.”

Going back to her maternal home wasn’t an option for Rupali, because in many parts of rural India, returning to the maternal home post-marriage is considered taboo. “Fearing the ostracism my maternal family would have to face, I rented a small room, but had no money to make ends meet and pay the rent,” she said tearfully. Despite these circumstances, every day Rupali kept risking her life as an ASHA to contain Covid transmission and make sure her community remained safe, “During this duty, I felt like I was about to die anytime because of the tremendous stress.”

This had such a tremendous impact on her that she was diagnosed with clinical depression. When Netradipa Patil heard of this, she started counseling Chavan and took her to a psychologist. “It took us six months, but we ensured she was out of depression,” Patil told me. As the counseling sessions continued, Patil also spoke to her family members, making them aware of the plight of ASHAs. She said Chavan’s “family members believed Rupali was lying about the delay in payment.”

Just as Chavan started to recover, her husband killed himself—likely driven to despair by household debt. Rupali’s depression returned, but after several more months of counseling and creating a support system of fellow ASHAs, Netradipa Patil told me, “Rupali is slowly getting back to normal, but it’s going to be a long struggle for all the ASHAs to fight this system.”

ASHAs protest outside the district public administrative office in Maharashtra’s Kolhapur district.(Sanket Jain)

In August 2020, ASHAs began holding rallies demanding the legal status of full-time workers, better and safer working conditions, and higher pay. During the protests, police charged more than 100 ASHAs in New Delhi with violating Covid protocols and for not having prior permission to hold rallies. Maya Patil had a criminal case registered against her after protesting outside a government office in Kolhapur. Then in June 2021 in Maharashtra, ASHAs went on strike. After nine days, the government agreed to provide them with smartphones and raise their monthly honorarium by $19. ASHAs went back to work. But according to Maya Patil, “Nothing happened. They haven’t given us the promised increased pay.” ASHAs across the country are again preparing to strike.

Maya Patil and Netradipa Patil are holding regular meetings with 20 to 30 ASHAs, where they discuss the government’s intimidation tactics and make the case that unionizing is best way to protect themselves and get their demands met. “We united all the 3,000 ASHAs in Kolhapur, and our union was so strong that all the cases here were repealed,” Maya Patil said.

In October last year, when payments were delayed by five months, the ASHA union called a strike, and the government released their payments within a week, according to Netradipa Patil. “The health department knows they will collapse if we stop working,” she said. “Unfortunately, always, it takes a protest for them to pay us.”

Asha means hope in several Indian languages, which for some in the community is bitterly ironic. “Our biggest mistake was hoping things would get better,” Kamble told me. “I’ve been working for 13 years as an ASHA, where I saved countless lives, and now I am diagnosed with diseases, which won’t go in this lifetime.”

Netradipa Patil told me that her biggest priorities are making sure that ASHAs avoid exhaustion and that their crucial work is acknowledged and fairly compensated. “Every ASHA has a horrific story to share, and it’s not easy continuing working in such stressful and toxic environment.” She added that she’s not giving up on the fight anytime soon: “It might take more time, maybe years, but we will keep protesting until our demands are met.”