ASSAM, INDIA — Dipa Saikia, a community health worker in Assam, northeast India, narrates a few harrowing details of trying to provide care during the South Asian monsoons. Every summer, humid winds rush onto the Indian subcontinent and hit the Himalayas, which forces the winds to rise; reaching the upper atmosphere, their temperature drops, causing rainfall. In Assam, June, July and August each bring a foot of rain in a typical year. “Monsoons are the worst time for us,” Saikia says.   

The most difficult ordeals involve transferring pregnant women from her village, Sesuguri, which sits on an island in the Brahmaputra River, to the nearest public health center for emergency deliveries amid torrential downpours. She recalls an incident in June 2022 when the Brahmaputra had risen and she had to cross the river three times on rickety wooden boats to escort her patient to the clinic. After a two-and-a-half-hour journey, she was able to deliver the newborn safely. Sometimes, they are not so lucky and the baby must be delivered on the boat.

As the planet warms, these conditions are expected to become more frequent. According to a report published by the Ministry of Science and Technology, Assam has the highest vulnerability to climate change of 12 states in the Himalayan region. Extreme rainfall is predicted to increase by up to 38% and floods by 25%, alongside a rise in temperatures by around 2ºC by mid-century, compared to 1971-2000 averages. 

According to a report published by the Ministry of Science and Technology, Assam has the highest vulnerability to climate change of 12 states in the Himalayan region.

In 2022, even before the onset of monsoon, Assam received incessant rains; with many areas submerged, agriculture was destroyed and millions became displaced. In the month of May alone, at least 30 people were killed in the state due to floods, and over a million people were evacuated and moved to relief camps. This year, too, the situation looks grim. According to official data, until the end of June, over 400,000 people had been hit by the deluge across the state.

Saikia is among India’s more than 1 million community health workers who provide the link between the country’s many rural communities and the public health delivery system, by connecting people to services, vaccinating door-to-door and, when necessary, physically escorting them to clinics. Though trained to deliver first aid, perhaps their most significant role is making reproductive, maternal and child health care accessible to people in rural areas and urban slums. Known as Accredited Social Health Activists, they were among the six recipients of the WHO Director-General’s 2022 Global Health Leaders Award, recognized for their “outstanding contribution towards protecting and promoting health.”

But with the limited infrastructure in many of the areas they serve, extreme weather puts ASHA’s like Saikia — and women and girls they serve — in increasingly dire circumstances. 

Mandira Buragohain, project officer at the Assam State Disaster Management Authority, said ASHA’s are going to bear the brunt of extreme weather’s impacts on health care delivery. “It is challenging in terms of transportation during the floods, and during the heat it is difficult for them to continue doing their daily work for long hours.” 

Assam already records the highest maternal mortality rate among India’s 28 states, and during floods access to reproductive health care and nutrition is disrupted for many mothers-to-be. Meanwhile, the facilities normally used to clean and dry the cloth materials that most women in villages use during menstruation become washed out and inaccessible. 

Yet these foot soldiers of India’s health delivery system have long been overworked and underpaid. In Assam, ASHA’s make 3000 Indian rupees per month (36.59 USD), far less than a government office worker. Saikia and other ASHA’s allege that, since March, they have been receiving Rs 1000 (12.20 USD) less than the amount they are supposed to get. They have been told by other senior health officials that it is due to “shortage of funds” and all the pending dues will be cleared at once in one of the upcoming months. 

The extra payment provided for each delivery of a child hasn’t gone up since 2006, said Jhuma Kundu Dey, an ASHA worker based near Jorhat, in Assam. Meanwhile, their responsibilities have increased. The national health mission’s Assam office did not respond to requests for comment.

“Whenever there is any emergency in the village, we are the first people that the community reaches out to,” said Bonti Pathori, also an Assam ASHA, and now, “we have had to do leprosy surveys over the past few months.” ASHA’s say that extreme weather events such as flash floods and heat have made their jobs even more difficult.

But with the limited infrastructure in many of the areas they serve, extreme weather puts ASHA’s like Saikia — and women and girls they serve — in increasingly dire circumstances. 

In Assam, for instance, every year, as the river Brahmaputra overflows, it brings severe destruction to lives and properties. As Saikia’s typical day involves walking house to house to deliver care, spread information and collect data, floods make the job even more difficult. 

Community health suffers as a result. Jollymoni Saikia (no relation to Dipa), gender coordinator at Northeast Affected Area Development Society, a not-for-profit based in Assam, said immunization for women often gets delayed during the floods. ASHA workers who deliver the vaccines are not able to reach places cut off by flooding. “The Health Department has made efforts for immunization to take place during flooding situations, but a lot of women are still left out of the process,” Saikia said.

Floods increase disease risk in areas with poor sanitation, such as much of rural Assam, putting ASHA workers themselves at risk as they conduct home visits during the monsoons amidst floodwaters and muck. 

Dey travels twice daily for home visits but if there is a high-risk case, she might have to travel more. Even in dry seasons, travelling in extreme heat can be dangerous. And Assam isn’t the only part of India that has been dealing with an extreme rise in temperatures; in May, the Indian Meteorological Department issued a heat wave alert for seven southern and central states, and extended it to New Delhi and some northern states.

Considering the vital services ASHA’s provide to their communities, Dey wonders why the government doesn’t do more to improve pay and working conditions so workers can continue providing their vital services to marginalized and vulnerable communities. “We were honored by the WHO for our work,” she says, “yet why are we so neglected?” 

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