The mental health impact of the pandemic has been acknowledged at both national and international level. A recent survey by the Indian Psychiatric Society showed a 20% increase in reported mental illnesses cases within a week of the lockdown. Unprecedented public health measures like the lockdown threw the ‘normal’ lives of people out of gear. Such extraordinary situations may lead to emotional difficulties like anxiety, depression, inadequate sleep, and appetite disturbances, as well as severe mental illness and substance misuse.
The impact of the pandemic on the mental health of front-line health workers (FHWs) has also been acknowledged, although the intricacies of how mental health issues unfold among these workers, and their relation to working conditions, are little explored. While gestures of lighting candles, clapping and banging plates to celebrate the contributions of FHWs are appreciated, it is important to ask if these symbolic expressions of care are enough to boost their morale. Do these gestures translate into meaningful provision of care, as FHWs cope with the pandemic that demands them to protect themselves and the community they serve?
‘Burn Out’ of Frontline Health Workers
According to official guidelines, ‘burnout’ is the most common disabling mental health issue experienced by FHWs. Burnout involves emotional exhaustion, depersonalization, and a decreased sense of accomplishment which can impact their competence and health care delivery. To avoid this burnout, the guidelines elaborate on the importance of ‘self-care’ for FHWs. It suggests individualised measures like adequate sleep, connecting with family and friends, exercise and diet and making time for yourself. At the health facility level it encourages individual team leaders to support mental health concerns through counseling services, information and training, regular breaks and team debriefings. In critical cases referral to the nearest mental health service is advised. At the policy level, guidelines urge policy makers to “honour frontline personnel” through local programmes and media platforms. Even as the mental health discussion goes beyond the private sphere, the remedies proposed remain fairly within personal capacities.
A recent webinar jointly organised by multiple organizations of FHWs from Uttarakhand, MadhyaPradesh, Chhattisgarh, Maharashtra and Delhi that I attended as a Rapporteur showed health care workers sharing their everyday experiences of working during COVID times.  One of the panelists, a male clinical nurse, explained:
“This new routine of wearing PPE kits, increase in caseload, dealing with traveling during lockdown, quarantines, unavailability of equipment, new guidelines rolling out every now and then, altogether has an impact on the mental health of nurses. Also, cases are increasing every day, we keep wondering how long this will go on? How will this end? These questions bother people.”
Other exhausting conditions described by FHWs were long working hours, staff shortages due to quarantining, inadequate access to food, liquids and rest, worries about infecting their own families, separation from families, outcasting from residentials areas as potential virus carriers, and difficulty in accessing domestic workers and care workers for their children.
These challenges are faced in varying degrees depending on FHW’s positionality and voice in the public health system hierarchy. The degree of burnout varies for doctors and staff nurses working at health facilities and for field workers like ASHAs (Accredited Social Health Activist) and ANMs (Auxiliary Nurse Midwives). Especially in the case of ASHA workers, research findings pre-covid19 show inadequacy and irregularity in pay, as well as pressures faced at home and work by ASHAs. As the pandemic tests the resilience of the already overburdened health system, ASHAs positioned at lowest rung in the health system hierarchy continue to be overworked and underpaid in risky working conditions, increasing the intensity of their possible burn-out. Conversations with FHWs in the webinar revealed challenging working conditions that increase the mental stress faced by ASHAs during the pandemic.
Dealing With One-Way Communications
The guidelines recommend discussing FHWs’ concerns, and providing them accurate information updates regarding the pandemic, as a way of offering care. However, frontline workers expressed discontent over the health department’s lack of communication regarding the intensity and risk of the infection. They were also not provided protection gear to perform the Covid-19 surveys, which put their own lives a at risk, as well the lives of those in the communities they serve. One ASHA facilitator explained that they were forced to rely on their own Whatsapp group networks, to track and share WHO guidelines directly among themselves, in order to stay informed about the safety measures that health workers should take.
This facilitator further explained how ASHAs are the face of the health department, and how their non-compliance in Covid precautions reduces their legitimacy in the public health domain and communities they work in:
“People are questioning the ASHA workers because [she] goes around telling people what to do but she herself did not have masks or sanitizer with her at all times and often made do with covering her mouth and nose with a ‘pallu’ (long edge of the saree) or ‘dupatta’ (long scarf).”
Data Collection as Congealed Labour
Accurate data collection and monitoring are crucial activities, so that policy makers can crunch numbers to plan public health measures that curb the pandemic. ASHAs therefore face a lot of pressure to do multiple surveys along with their routine work. However, they wonder why the collected data is so valued while their labour and time congealed within the data remain undervalued. One of the panelists in the webinar puts this concern in perspective:
“So what happens if the ASHA decides to sit at home in this pandemic and not collect data and not provide information? We will never know if migrants have come to the village and their numbers. There are 10 lakh (1 million) ASHA workers approximately. Does the health department have any other workforce who can collect this data? Is there a workforce who will conduct surveys, monitor quarantines, follow-up on them, create awareness among people, follow the government guidelines and do all of this work, just based on the goodness of our hearts? Because we don’t get much to do all this work. Now you know why we become mentally ill.”
Fighting for Better Pay
Insufficient and irregular payments to ASHA workers are not a new phenomenon, but a pre-Covid-19 characteristic of the public health system that continues in the post-Covid-19 period. The initial lockdown temporarily suspended routine health services in some states, affecting ASHA payments as they are task-based incentives. Since the pandemic, ASHA workers have organized strikes in different states of the country demanding fixed payments and better protective gear. Another panelist elaborated on how the system drives ASHA workers toward a mental health crisis:
« Our physical and mental conditions are most affected by our material conditions (arthik avastha). The government made a big announcement that the ASHA workers will be paid Rs.1000 and ASHA facilitators will be paid Rs.500 for corona work. If you calculate this it comes down to Rs.30 per day. We use sanitizer, soap and masks worth more than Rs.30 every day. We make an investment of more than Rs.30 in transport each day as sometimes our nearest field location is 12-13kms away and farthest is 25-30kms and we must travel without public transport available.”
The experiences of FHWs highlight the need to recognize their mental health problems produced by their working conditions, which expose them to varying intensities of burnout and mental strain. The symbolic expressions of care and gratitude and overarching recommendations of ‘self-care’ for all frontline workers may be a genuine reaction to real fears of coronavirus, but it is not enough given the working conditions of healthcare workers. The FHWs seemed to be well aware that this expression of care is a response to the now growing and obvious burden on the FHWs and their indispensability in managing the pandemic. But this may not translate into recognition of their material conditions, or addressing these. As one of the panelists asks, “Today the government is saying yes ASHAs are doing good etc., but ‘till when will they do this? Can we keep this up at all times? Don’t nurses, ASHAs, health workers work at all times?”
Conversations with FHWs reveal that while the pandemic’s overall impact on mental health is well acknowledged, there needs to be more discussion about the different ways the pandemic aggravates existing institutional behaviours and poor working conditions for healthcare workers that contribute in turn to the ‘mental health crisis’.
This article is based on the Webinar- Being at frontline of Covid 19: Conversations with the Grassroots Healthcare Workers in India, guided by Prof. Arima Mishra.
 Sahoo, Harihar & Biswal, R.K., 2020. « Impact of Covid 19 on Mental Health: Whether India is prepared to handle the crisis?, » MPRA Paper 100765, University Library of Munich, Germany.
 NIMHANS. 2020, April. ‘Psychological Issues of Frontline Personnel Combating COVID-19’ Mental Health in the times of COVID-19 Pandemic Guidance for General Medical and Specialised Mental Health Care Settings. P. 52-56. Department of Psychiatry. NIMHANS, Bengaluru.
The webinar was organised by Centre for Health and Social Justice (CHSJ), Forum for Ethics and Medical Society (FMES), Azim Premji University (APU), Innovative Alliance for Public health and Community of Practitioners on Accountability and Social Action in Health (COPASAH)
As the Rapporteur, I recorded the proceedings and minutes of the webinar and I’m also currently working as a Research Associate with Azim Premji University (one of the webinar organisers) on a project documenting frontline health workers’ experiences during Covid19
 National Health Systems Research Center (NHSRC). 2011 ASHA Which Way Forward? New Delhi, India: NHSRC
 Bhatia, K. 2013. Stakeholders’ engagements with the community health worker: The Accredited Social Health Activist (ASHA). Report for Ashavani, an e-platform
 Bhatia, K. 2014. Community health worker programs in India: a rights-based review. Perspectives in Public Health. 2014; 134 (5) : 276-282
 Mishra, A., Bandewar, S., Gautam, S. (2020, July 15). Being at the frontline of COVID 19: Conversations with grassroots health care workers [Web log post].
 Wood, H and Skeggs, B. Forthcoming, 2020. “Clap for Carers? from Care Gratitude to Care Justice.” European Journal of Cultural Studies. Vol. 0(0), p.1-7 https://doi.org/10.1177/ 1367549420928362.
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Sanjana Santosh is an independent researcher in the domain of health and development, currently working as a WHO-SEARO Research Fellow on Midwifery in Indian Public Health System. She also works as a Research Associate with Azim Premji University on a project documenting frontline health workers’ experiences during Covid-19. She holds a Masters in Development Studies, Azim Premji University, Bangalore.