ISSN (Print) - 0012-9976 | ISSN (Online) - 2349-8846
-A A +A

Our Essential Workers Need Essential Care

Nikhil Srivastav (nikhil@riceinstitute.org) is a researcher with r.i.c.e., a research institute for compassionate economics. Aditi Priya (aditipriya83@gmail.com) is associated with LEAD at Krea University. Payal Hathi (payal@riceinstitute.org) conducts research with r.i.c.e. and is a graduate student at the University of California, Berkeley.

Through personal interviews of healthcare workers in India, the state of front-line workers in dealing with Covid-19 in the country is discussed. Lack of personal protective equipment and beds as well as the caste system that operates when it comes to doing cleaning work in the hospitals aggravates the already debilitating condition of healthcare personnel. Despite being the most important stakeholders of health in rural areas, the accredited social health activists are leading a life full of struggles.

One of the biggest worries that epidemiologists, medical practitioners, and governments across the world have cited during the COVID-19 pandemic is running out of healthcare resources—hospital beds in wards and intensive care units (ICUs), and ventilators. But for anyone who has visited ­India’s public hospitals even once in their life, this has been a harsh reality for decades. Having two patients on the bed and one on the floor is not an uncommon sight, even in the maternity wards that receive a larger share of funds under the Indian government’s National Health Mission (NHM). India’s public health system was already failing many of its citizens and staff. Now COVID-19 has emerged as the latest crisis and is worsening the delivery of health services.

In this article, we strive to attract attention to the existing gaps that are widening during the pandemic, and how they may be affecting everyone’s health. In the first section, we discuss the lack of protective equipment for health workers. Second, we look at how overcrowding and inadequate staffing in hospitals is affecting care during the COVID-19 pandemic. In section three, we talk about how hierarchy in public health institutions makes infection control difficult; and section four explores issues that health workers working outside the hospitals are facing.

To reflect on how this current pandemic is interacting with a struggling healthcare system and the challenges it poses, we use learnings from interviews we have done during the pandemic, and before, with many different health workers—doctors, nurses, cleaners, accredited social health activists (ASHA), auxillary nurse midwife (ANMs), ward boys and ward aayas—in North India.

In mid-March, when a resident doctor in King George Medical University in Lucknow contracted COVID-19, his colleagues demanded personal protective equipment (PPE), while citing growing community spread. Their demand was later turned down by the hospital administration. The letter from the administration said,

According to ICMR/WHO guidelines N-95 mask and PPE are mandatory for Doctors and Staff who are treating Corona Virus ­Positive patients or involved in diagnosis of COVID-19 … For doctors and paramedics ­involved in OPD and emergency care of patients, 3 ply mask is sufficient.

The Lack of Protective Equipment

It is true that, during this pandemic, medical facilities across the globe are facing a dire shortage of PPEs, but the surprising part here is that when this letter came out, on 23 March, there were only about 500 reported COVID-19 cases across the country. Was the Lucknow medical school, so early in the pandemic, facing PPE shortages?

Moreover, making PPEs mandatory only for staff dealing with COVID-19 patients, as the letter cites the Indian Council of Medical Research/World Health Organization (ICMR/WHO) guidelines saying, does not mean that the staff dealing with non-COVID-19 patients should not be following infection control protocols. Outpatient departments (OPDs) and emergency rooms are the first point of contact with patients, and if the staff there is not being provided enough protective gear, hospitals are, in fact, putting the health of their staff and patients at risk.

A resident doctor in a medical college describing the current situation told us,

In my OPD, if I ask for a COVID test done for—let us say—a hundred patients, about ten results are coming back as positive. We have a sustained community spread. Emergency rooms have a similar situation. COVID test results can take from 24 hours to up to 48 hours to come, so during this time patients are getting housed in what hospitals call an “holding area.” This means that everyone—from potential COVID patients, to patients with other morbidities, doctors, paramedics, ward staff, and cleaners—all remain in the same environment without appropriate ­protective gears.

He added, “Yesterday, I had a patient who was coughing in my face. Today, when we got his test results back, he is a confirmed COVID-19 patient.”

Soon after the test results came, this patient was shifted from the “holding area” to the COVID-19 ward, however, we do not know if some staff or other patients who were around him contracted the infection while he waited for his test results. If another patient or staff person did contract the infection in the “holding area,” they could become super spreaders of COVID-19. The lack of protective gears for non-medical and medical staff outside the COVID-19 wards and ICUs to be worrisome.

Overcrowding and Inadequate Staffing

Two of the authors of this article visited a large district hospital in Madhya Pradesh (MP) in 2016. What we saw in the hospital ward was startling. The general ward had a pile of waste—which included needles, intravenous bags, bloodied cloth, empty injection vials, and discarded food, biscuit wrappers, and plastic cups—right outside its door. The ward was housing far more patients than the number of beds it had. To accommodate the extra load of patients, the hospital administration had arranged some mattresses and sandwiched them in the spaces between beds.

Unhygienic conditions, like the one we saw in this hospital ward in MP, are risky because they could become hotbeds of infection. As we strolled around the ward, we kept on wondering: Why was this place so filthy? Like some other problems in the hospital, was this also due to negligence from the staff?

It is true that some hospital staff do not show up on time, and that some take long breaks during their shifts. How­ever, if everything else remained the same and these workers, instead, were punctual and conscientious, would public hospitals be able to maintain more hygienic conditions and mitigate the risk of hospital acquired infections? Perhaps, the answer here is no.

According to the National Health Profile 2019, published by the Ministry of Health and Family Welfare, there are a little over seven lakh beds in public hospitals across India (Central Bureau of Health Intelligence 2019). As compared to Sri Lanka, which had about 360 hospital beds per one lakh population in 2012, this is equivalent to about 60 hospital beds per one lakh population. More densely populated states in the northern plains have an even more dismal ratio. In Uttar Pradesh (UP), for instance, there are about 38 beds per one lakh population, and Bihar only has about 11 hospital beds per one lakh population. This leads to overcrowding of hospitals, which is dangerous because it can lead to the spread of infection, and is particularly dangerous in times of COVID-19. Having more patients than a facility is designed to handle has some serious consequences for infection control, as the maintenance of 1 metre of distance between beds becomes impossible.

The severely inadequate availability of hospital beds in the population, which is the result of repeated government decisions to cut public expenditure on health, is only part of the problem of overcrowding (Sen and Dreze 2013). Another important consequence of meagre government spending on health is inadequate staffing, which leads to over-reliance on patients’ attendants to provide patient care (Karan et al 2018).

Unlike in some societies, where patients who are admitted to hospitals are fully taken care of by health workers, patients in India are accompanied by several of their family members when admitted. Hospitals rely heavily on attendants to buy medicines from nearby pharmacies, and even perform the tasks of a trained paramedic, such as informing staff if the blood oxygen level in a patient goes below normal. Attendants, in many cases, also play an important role in advocating for better care for their patient. However, their constant presence further overcrowds hospitals, adding to the ­burden of the cleaning staff, and poses hurdles in the enforcement of infection control policies. This makes everybody—the patients, the attendants, and the hospital staff—vulnerable to infections. During COVID-19, public hospitals, for good reasons, are trying to keep attendants out of facilities. But they are not adequately staffed to provide all necessary care to their patients.

In an incident, which we learned about after talking to an ASHA, a hospital nurse, refused to offer delivery care to a pregnant woman because her COVID-19 status was unknown. According to the ASHA, this led to the death of the woman’s unborn child. The ASHA told us, “We kept requesting her but she refused to touch the pregnant woman, who lost her first child in the hospital itself.”

Hierarchy: Social and Institutional

A study by Newcastle University, published in the Lancet as a correspondence, analysed 1,000 tests carried out on workers at a hospital in England. It found that the number of health workers testing positive was no different from that of staff working in non-clinical roles like the cleaning staff, suggesting that staff across health facilities face similar occupational hazards. But sadly, in Indian health facilities, non-medical staff receive fewer trainings and protective equipment. Below, we will show that this difference in treatment is being driven by the caste system, a historical system of social classification.

An indicative estimate, based on the National Sample Survey Office’s 68th round data, suggests

that the share of Dalit workers in the occu­pations of the healthcare sector [medical professionals] is far below as compared to other social groups and is notably under-represented as a proportion to their total population in both rural and urban India. (George 2015)

In stark contrast, however, when it comes to the cleaning staff in the hospitals, almost everyone is a Dalit.

A sanitation supervisor in a district hospital in Bihar, in 2017, told us that people from “non-sweeper castes” do not want to take up the cleaning jobs. He said, “No, they don’t want [these jobs]. This is a hospital so of course there will be blood, wounds, tuberculosis, all kinds of other ailments. Many people find this disgusting.”

Unless someone is a high-ranking doctor, nurse, or a pathologist, dealing with body fluids and excreta is considered polluting and dirty, according to the casteist rules of purity and pollution. And these high-ranking staff, too, when working closely with body fluids, limit their work to performing medical procedures. Cleaning the blood and mucus on surfaces after check-ups or procedures falls on cleaners. For example, when doctors and nurses help pregnant women deliver babies, even on a busy day, they never clean the delivery table. Many told us that if a sweeper is not available, “the dirtiness will stay.” While it is acceptable and even expected for cleaners to help with other people’s tasks, no one among the hospital staff is willing help with their work.

Because of their caste, cleaners in hospitals often face discrimination. “The rules are given. So, if someone is a sweeper, they can’t come in this area, eating with them is not supposed to be done. This all has been going on for a long time, so one doesn’t feel that there is anything wrong with it. This is why some distance is maintained,” a nurse explained when we asked about the relationship between cleaners and the rest of the staff. In hospitals, even if a chair is vacant, it is expected that cleaners will not sit on it. They either sit on the ground or on a stool that is dedicated to them. Repeatedly, through these actions and justifications, cleaners are shown their place in the “institutional hierarchy.”

The low status of cleaners in the social and institutional hierarchy and the outright discrimination from staff in higher-ranking occupations means that cleaners lack the agency to even demand their legal rights, like asking for protective equipment (Hathi and Srivastav 2020). In an interview with Firstpost, a cleaning staff person at Gandhi Hospital, ­Hyderabad, said

It is my job to clean up the ward after any surgeries or operations. I have neither been given a mask, nor gloves or any proper medical kit. I use a mask that I buy myself. Otherwise, I just wrap a dupatta over my face.

Hygiene and infection control at hospitals requires a combined and orchestrated effort from all its staff. But, given that cleaning staff rarely receive any support from their colleagues or patients’ attendants, the burden of keeping the facilities clean falls squarely on their shoulders. Now, in this highly contagious environment of COVID-19, it is all the more important to do away with our caste prejudices, recognise their work, and provide them with infection control training and protective gear.

Health Workers Outside the Hospitals

Many of the problems that we have discussed so far have focused on the healthcare facilities, but, with the sustained community spread of COVID-19 that the country is now witnessing, rural health workers like ASHAs are facing several challenges as well.

ASHAs are honorary volunteers, so they do not receive any salary or honorarium, and their monthly remuneration depends on the type of work they do in a month. According to the National Rural Health Mission (NRHM) guidelines, they have been assigned 43 different functions—from raising awareness on health and nutrition, to providing primary medical care, to promoting toilet construction, taking pregnant women to hospital for deliveries, and bringing children and pregnant women to immunisation sites. Now, during COVID-19, about a million ASHAs have been assigned the work of conducting door-to-door surveys, educating people about the pandemic and necessary precautions, and tracking and ensuring that returning migrant workers are placed in a 14-day quarantine. They have been asked to do this on top of the work they were already doing.

The workload for ASHAs has increased manifold during COVID-19, increasing the hardships they face in their work. An ASHA in UP with whom we spoke in early July told us that, since March, neither she nor her colleagues have received any payments for their work of facilitating institutional deliveries. The only money they have received in the name of “corona duty” since the lockdown began was `2,000. In Bihar, some ASHAs told us that they are still waiting to receive any money for their COVID-19-related work, even though they have been going out and doing door-to-door work. Unfortunately, this is not a rare occasion when ASHAs are struggling to get their entitled incentives.1

Although ASHAs have been given critically important tasks during COVID-19, such as visiting households to identify likely COVID-19 patients, and even managing block-level quarantine facilities, they face other hardships in addition to not being paid on time. For example, none of the ASHAs we talked to have received proper training on COVID-19, its symptoms, or the do’s and don’ts of wearing a face covering. Moreover, since the start of their COVID-19-related fieldwork, several said that they have received a mask from the government only once, and that too of poor quality.

On 29 March, under the Pradhan Mantri Garib Kalyan Yojana, the Fin­ance Minister, Nirmala Sitharaman announ­ced an insurance cover of `50 lakh for 90 days to workers performing COVID-19-related work. The insurance scheme covers the loss of life due to COVID-19, and accidental death on account of ­COVID-19-related duty. However, the insurance scheme does not cover the cost of medical expenses in case of illness, leaving low-paid workers like ASHAs, or cleaning staff, vulnerable in the case of a long COVID-19 illness. In addition, the 90-day period of coverage has lapsed, and it is unclear if it has been extended. Moreover, the ASHAs are unclear if the insurance scheme even applies to them. The ASHAs we spoke with were confused because they have not received an official word about the scheme. Instead, all that they know about it is from news stories, family WhatsApp groups, and neighbours.

An ASHA in Bihar described her hardships and disappointment of the government’s appreciation and support as,

Almost every day it used to feel like I would die working in the field. No shops were open to buy food, there was no transport available to travel, and all we got from the government was Rs 1000 for a month.

The ASHAs in the past have been instrumental in improving the rates of immunisation and institutional deliveries, and there is no doubt that they can help in check-ups and contact tracing as the pandemic unfolds in rural India. But by not paying them on time, not providing them protective equipment and the necessary training, we are demotivating them. If governments continue to not care about these front-line workers, we will not only hurt them but also the rest of the citizens.

Conclusions

It has now been over three months since the WHO, on 11 March, declared COVID-19 as a pandemic. So far, over 6.5 lakh people worldwide and over 36,000 in India have been reported to have lost their lives. Experts believe that the worst is yet to come. Countries, including India, are all at different stages of the pandemic. However, they are still facing the first wave of infections. We know neither how far the end date of the pandemic is, nor how countries will face the second wave of infections, even if they successfully manage the first. How effectively India is able to “flatten the curve” and how well it can help in the recovery of those who will suffer from the disease, depends a lot on our health workers. We should care for all of them all the time, but now, in the COVID-19 pandemic, it is extremely ­important to offer gratitude, protection, and compensation to the cleaners, ASHAs, and the trained medical staff on whose efforts much of the healthcare in India depends.

Note

1 A study sponsored by the State Innovation in Family Planning Services Project Agency (SIFPSA) of UP claimed that 73% of ASHAs in UP reported not receiving full payment for their work because they were forced to resort to bribery.

References

Central Bureau of Health Intelligence (2019): National Health Profile, Ministry of Health and Family Welfare, Government of India, New Delhi.

George, S (2015): “Caste and Care: Is Indian Healthcare Delivery System Favorable for Dalits,” Working Paper 350, the Institute for Social and Economic Change, Bengaluru, http://www.isec.ac.in/WP%20350%20-%20Sobin%20George.pdf.

Hathi, P and N Srivastav (2020): “Caste Prejudice and Infection: Why a Dangerous Lack of Hygeine Persists in Government Hospitals,” Economic & Political Weekly, Vol 55, No 16, 18 April, pp 38–44.

Indian Council of Medical Research (2016): “Hospital Infection Control Guidelines,” Indian Council of Medical Research, New Delhi.

Karan, A, H Negandhi, R Nair, A Sharma, R Tiwari and S Zodpey (2018): “Size, Composition and Distribution of Human Resource for Health in India: New Estimates Using National Sample Survey and Registry Data,” BMJ Open, Vol 9, No 4, https://bmjopen.bmj.com/content/9/4/e025979.

Sen, A and J Dreze (2013): An Uncertain Glory: ­India and Its Contradictions, Princeton, NJ: Princeton University Press.

 

Updated On : 3rd Aug, 2020

Comments

(-) Hide

EPW looks forward to your comments. Please note that comments are moderated as per our comments policy. They may take some time to appear. A comment, if suitable, may be selected for publication in the Letters pages of EPW.

Back to Top