Harsh Mander: The many sacrifices of unsung heroes on India’s Covid-19 frontline

Sanjeev Choudhary described himself as a logistics services professional. He mourned the loss of his wife to Covid-19. “My wife died with regrets – of not seeing her children grow, graduate, marry, among many such unfulfilled wishes of life,” he said.

He was bitter with unanswered questions about what it was that took the life of his wife. “It is impossible to tell if it was the virus, or the isolation of a hostile environment with beeping ventilators and emotionless strangers clad in the protective kit, or a political system for which the life of the citizens is cheap and neglectable with impunity, or the stress of ballooning medical bills that brought her family to the brink of bankruptcy that became the major reason in her finally giving up the fight,” he told The Print.

But amid all his grief, he “saluted all those selfless heroes who stood up against all odds to help in whatever way they could. Their selfless acts made the pain a little less”. These many strangers “helped like if they were god-sent angels”. Who were these angels?

“Despite the pressure, doctors, nurses and the cleaning staff did a stellar job,” Choudhary told The Print. “I could see a sense of frustration building up in them because of the lack of medicines, oxygen, rest and dealing with patient’s relatives. They were fighting a two-front war, one with the virus and the other with anxiety and fatigue, with their hands tied behind. Their contribution is second to none”.

According to the National President of the Indian Medical Association, JA Jayalal, at least 650 allopathic doctors died in India due to Covid-19 during the second wave of the pandemic in India. The largest number of doctors’ deaths, 109 during the two months of the second wave, were recorded from the national capital of Delhi. The states next on this grim roll call were Bihar and Uttar Pradesh. The number of doctors’ deaths in 2020 was stated by the Indian Medical Association to be 864.

Doctors indeed fought brave and sometimes pitched battles against many adversaries: the virus was only one of these. When the oxygen crisis peaked, doctors appeared on national television, sometimes weeping, about their helplessness in saving the lives of their patients because the hospitals had run fatally short of something as elementary as oxygen.

Others complained about faulty supplies, such as of ventilators. One of these, Dr Neha Agarwal, a doctor in Kanpur called out sub-standard ventilators provided under the PM-CARES Fund. Her reward was a suspension order for “medical negligence” which allegedly caused a child’s death. Dr Agarwal, who led the paediatric unit in the Ganesh Shankar Vidyarthi Memorial Medical College, had complained about two ventilators supplied by the indigenous Aqva Healthcare company, received by the department under the PM-CARES Fund, which she said were faulty because they worked only intermittently.

According to her, a child died because one such ventilator stopped working abruptly. The child was battling tuberculous meningitis. Her superiors in the hospital first supported her claim, but the matter became a political hot potato after Rahul Gandhi, senior Congress leader, tweeted about this, and eventually, the officer herself was suspended, blaming the death of the child to her neglect.

Unsung public servants

The Indian Medical Association fittingly describes the doctors who died in service of patients with Covid-19 as martyrs. But there are many other martyrs as well, those at the lower ends of the public health hierarchy, who were highly stretched, barely recognised, rarely celebrated and almost totally unprotected. I will devote this chapter to some of these unsung public servants.

Prominent among these is the multitude of community health workers in every corner of the country. Azim Premji University compiled the voices of 20 of these women from ten states including Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Chhattisgarh, Arunachal Pradesh, Madhya Pradesh, Odisha, Rajasthan and Maharashtra. Many of these are Accredited Social Health Activists, village-level health workers recruited by the community members and accountable to them, responsible for mobilising community members to access public health services along with her broader role of creating awareness about health and its determinants in the village.

Srishti was an Accredited Social Health Activists supervisor from Bhind District of Madhya Pradesh. Workdays during the national lockdown were punishing, long and tiring. Public transport was suspended and she had to look for a chance lift or even sometimes walk for six hours to reach the villages under her charge. She said that all the Accredited Social Health Activists, herself included, “fear[ed] contracting Covid-19. This fear was further aggravated by the fact that they were not given protective masks or sanitisers by the Health Department…Accredited Social Health Activists were in close contact with the families in quarantine, collecting malaria slides, and attending meetings, making them more prone to infection”.

Accredited Social Health Activists themselves pooled money to buy soap and stitch cloth masks for themselves, as the single set of disposable masks provided by the government were patently inadequate.

She spoke with an empathy – that is mostly missing in senior levels of government – of the impossibility of families isolating members who returned from other states or districts. Their homes were either not habitable, or did not have enough space, toilet facility, or a water connection to quarantine safely. And poor families without enough money and food had to step out to seek work.

“How can ASHAs [Accredited Social Health Activists] ask families to focus on washing hands with soap and stay home when they are hungry?” she said. “So we suggest that they may go to the field to work. However, we insist they cover their mouth and nose with a clean cloth.”

She however complained that Accredited Social Health Activists were themselves “treated like “stepchildren” – blamed for problems and not considered with empathy”. The government lists and circulars were “as though we do not exist”.

“While the gratitude expressed towards frontline workers mentions doctors, nurses, waste collectors and others, no one mentions ASHAs, even when we work in risky conditions... and often go beyond our designated tasks. Are we not the frontline warriors?” she asked.

Shilpa, another Accredited Social Health Activist in Gwalior city in Madhya Pradesh, also spoke of difficulties in travelling to the field in the summer heat without transport facilities and the grossly insufficient personal safety gear issued to them even when they were posted in containment zones.

She said she felt helpless during the lockdown because she could not assist people because health facilities were ill-equipped or unavailable. Normal health systems were thoughtlessly disrupted.

“Now, all patients, whether those with heart ailments, a fever, or even from the neurology department stand in the same queue for medicines,” she said. “Earlier, there would be different counters but now the government has ruined the system and people stand in a queue from 7 am to 6 pm, and sometimes even wait back till the next day.”

Without a strong primary healthcare system, people were compelled to travel to distant places on their feet. Ambulances were unavailable, and the police failed to respond to their pleas to help transport their patients even when the patients are very sick.

Pakha had worked, when Covid-19 swept the country, as an Auxiliary Nurse Midwife for 12 years in the Lower Subansiri district in Arunachal Pradesh. Pakha had a small child, and she worried about him. When she returned home from Covid-19 work, she would carefully bathe and wash her clothes before going near the child. “One has to take utmost precautions with a small child at home. What else can we do?”

Hema, an Auxiliary Nurse Midwife for two villages of Kanker District, Chhattisgarh, spoke of the fears for her safety endured by her family. But she convinced her son who worried about her: “We all are going to die anyway, but before dying, we might as well do something good and worthwhile for humanity and for our community. Our job is to serve people, and we cannot stay back.”

Even so, she was hugely hamstrung without resources and training. “I only had information, no treatment for Covid-19,” she said. “It was important to communicate that prevention is the only way. I instructed the team to meet every person – from children to old people, visit every household in the village, and make them aware by asking them to adopt preventive measures like physical distancing, regular hand washing, and use masks when going out.”

She also requested village shopkeepers to keep a bucket of water and soap outside their shops. “The community and I were both afraid,” she said. “But, as they say in that advertisement – “Darr ke aage jeet hai [Beyond fear, there is victory] – it is the same with us. Earlier, there were no Covid-19 cases, but we were so fearful. Now, there are many positive cases but the situation is calmer. We are alert and ready. Through our efforts, people have become aware.”

But the suicide of an ailing man left Accredited Social Health Activist Shilpa badly shaken. He had said to her a few days earlier that he had no money or medicines. In times like this, she felt “helpless, de-skilled and unheard despite dedicating years to the State Health Department”. She also spoke of her own distress, “Sometimes I feel so emotionally distressed with the lockdown, the unending work, and financial problems. We are talking about other people’s health but our own conditions are precarious. We ourselves are emotionally stressed.”

Teachers on election duty

This brief account of the unsung heroes of the pandemic would be incomplete without the disgraceful epic of the mindless deaths of possibly more than 1,600 teachers forced into election duty for the Uttar Pradesh Panchayat Elections, rammed through by the state administration from April 15-April 29, even as people were dying everywhere in the fury of the second wave.

The Uttar Pradesh Prathmik Shikshak Sangh, a union of primary teachers documented 1,621 teachers and staff who lost their lives during election duty. The state administration characteristically displayed no remorse.

It peremptorily (and angrily) denied the figures, and claimed instead that only three teachers had lost their lives to Covid while on panchayat poll duty in the state. Later the State Election Commissioner told the Allahabad High Court that in 28 districts for which details were available, 77 polling officers had died.

Dipankar Ghose, a reporter with the Indian Express travelled to Gorakhpur, the constituency of the Chief Minister of Uttar Pradesh, to bring us the stories of loss and wrath from two families destroyed in this mindless, cruel and entirely avoidable conflagration. Parvati, a 40-year-old assistant headmaster at a government school in Paridih, reported for poll training in Gorakhpur city.

“There was a huge crowd and absolutely no safety precautions,” her husband Prajapati recalled. “When she came home, she felt a little unwell, with fever and cough.”

His parents too soon displayed similar symptoms. They found a hospital for his father after many hours of searching, but it was by then too late and he died. A week later, his mother and Parvati both were breathless. His mother died the next day. Parvati finally got a bed in the medical college in Gorakhpur. After some time, she phoned desperately that she wanted to return home. He then got a call from the hospital to take her back, as she had no chance to survive. Soon after, she was dead.

Three kilometres away, tragedy similarly swooped down on the home of Amit Raj, headmaster of a primary school in Deoria, and his wife Anita Raj, a teacher at a school in Sardar Nagar. Both spoke to Ghose of election duty in which there was “no safety, just crowds”.

Returning from election duty, both developed a racking fever and body pain and tested positive for Covid-19. Members of their family became infected rapidly. Anita’s brother, his wife, and their father, all died in rapid succession, each gasping for breath as the family searched vainly for hospital beds. The family spent more than Rs 2 lakh on oxygen, hospital bills and medicines. Her brother and his wife left behind four children.

K Vijayendra Pandian, District Collector of Gorakhpur, was again in denial, even as on May 17, Gorakhpur had 6,519 active cases, with 569 deaths. “Generally, the numbers are high, not only because of elections,” Pandian told the Express. “Around eight people who died of Covid were directly involved in the elections. I have written to the government for compensation and employment for one family member.”

The teachers and families of the dead are vehement in their disagreement. “It was no festival of democracy. It was a festival of death,” Shiv Shankar Prajapati, an advocate in Gorakhpur’s Ranadeeh village angrily told the Indian Express. “If the elections had not happened, none of this would have happened,” Amit Raj, headmaster of a primary school in Deoria, added, still mourning the three people he loved who had died.

Crematorium workers

Equally unprotected were crematorium workers, trapped within this grim unsafe work by their birth in the lowest depths of India’s caste system. Puja Bhattacharjee from The Wire spoke with Bishnu (name changed) who worked with the electric furnaces of the Dhapa crematorium in Kolkata.

He had learned the trade from his father, and had, in turn, passed it on to his son. The works enabled them to bring food to their plates, but they had to keep their profession a closely-guarded secret, from their landlord (who would have evicted them, had he known) and their neighbours (who would have shunned them, and demanded their eviction).

The crematorium in which they worked in normal times catered to burning the animal carcasses and unclaimed bodies of destitute people who had no family or friends. But during the pandemic, this was earmarked for cremating those who died due to Covid-19.

During the second wave, Bishnu would cremate “90 to 100” dead bodies in a day. Another worker recalled, “The whole area would be filled with bodies. Sometimes we felt sad looking at them lying there like that.”

The workload was so heavy, they had to stay even during the nights at the crematorium. “The crematorium has a room where I stayed and cooked for myself for 14 days.” Bishnu told The Wire. They would often be in a surly mood, and barely talked. A psychologist Natasha Ryntathiang observed that these were signs of stress and burnout. “They were mentally exhausted because they are dealing with death in huge numbers,” he said. “The experience of dealing with the dead can be overwhelming.”

Sanitation workers

At the bottom of the heap were sanitation and waste workers. A waste picker Pawan, a migrant from Gorakhpur in Uttar Pradesh to Delhi regretted that “We do not get the same respect as doctors even when we put our health at risk every day”. He handled even in normal times the garbage of more than 100 houses.

When Abhimanyu Chakravorty, a reporter for the Indian Express, asked him if he feared contracting Covid-19, he replied, “Karein to kya karein? Bina khaye mar jaaye? Dar hai lekin bhookha peth marne se acha hai kaam karoon. Mere paanch betiyan hain ghar pe [What do I do? Should I starve to death? I am scared but not as much as dying on an empty stomach. I have five daughters at home].”

There were unconscionably grave dangers to waste pickers during the pandemic from medical waste contaminated with bodily fluids from hospitals, quarantine centres, and home quarantine, as well as discarded face masks, gloves, tissues, cotton swabs and syringes.

The risks of waste collectors like Pawan of contracting Covid-19 were particularly high from handling unmarked medical and contaminated waste because typically medical waste is not separated from other waste, even for those who work in waste dumps of hospitals. They mostly “work without safety gear, have no social security, face rampant discrimination, but still keep our cities clean”.

Amnesty International, WaterAid and the International Dalit Solidarity Network called on authorities in India, Bangladesh, Nepal and Pakistan to take immediate action to protect sanitation workers who are risking their lives on the Covid-19 frontlines. They said, “Across South Asia, workers cleaning toilets and streets, emptying latrine pits and maintaining sewers are faced with acute health and safety risks.”

“They lack adequate personal protective equipment, training support to cope with risks, job security, social security, health insurance and access to handwashing facilities,” they said. “The caste dimension of sanitation work in these countries also means that workers are highly stigmatised and discriminated against when accessing services or seeking other occupations”.

The Ministry of Health and Family Welfare issued a directive that sanitation workers in hospitals and other places should be provided with personal protective equipment. But when my colleague in the Centre for Equity Studies, Sagar Kumhare, investigated whether these directives being followed, the picture that emerged was dismal. He reported that, for instance, in Madhya Pradesh’s Panna district, a local activist petitioned the District Collectorate office to urgently supply protective gear to the sanitation workers.

A few days later, a phone came in from the office of the Collector, that the Madhya Pradesh government currently did not have an Urban Development and Housing Minister, and therefore the state government was not sending any money across for the procurement of protective equipment. Sunil Yadav was a PhD fellow from Tata Institute of Social Sciences and, unusually, himself a sanitation worker.

When Kumhare asked him what had changed for sanitation workers, he replied dispiritedly, “Nothing, nobody cares”. He went on: “Everyday sanitation workers get exposed to deadly trash but no special training or guidance is provided to them on how to handle trash.”

A 58-year-old sanitation supervisor at Delhi’s All India Institute of Medical Sciences died four days after testing positive for the virus four days earlier. According to a PTI report, the General Secretary of the All India Institute of Medical Sciences’ Resident Doctors’ Association wrote on Twitter: “Another corona warrior sacrifices his life in service of the country. AIIMS has lost its proud warrior. The virus is dangerous very communicable and does not spare anyone.”

A day earlier, a mess worker at the institute died of the disease. The Resident Doctors’ Association wrote to the All India Institute of Medical Sciences Director, “A mess worker from RPC canteen died of Covid-19 because the hostel section refused to take precautionary measures as demanded by RDA more than a month ago.”

Fear lurked constantly in the minds of sanitation workers. A sanitation worker activist from Panna district of MP told Kumhare from The Wire, “Our people are facing the coronavirus pandemic with courage, but there is always a fear in their minds: what if I get infected with the coronavirus? Who will take care of my family and children? Who will feed them?”

“Sab log corona ke dar se ghar me hai, hum to yaha pe usise ladh rahe hai firbhi humari koi kadar nahi hai [Everybody is at home because of coronavirus, but we are here fighting it. Even then, there is no appreciation]”, said Radharani, a sanitation worker at Panna, Madhya Pradesh.

“This neglect always existed, even historically, because we are Dalits”, said one worker. “No one is bothered about the unhygienic and undignified working conditions we have to bear.”

“Today, in the time of the pandemic, this indifference continues,” he said. “We should never have to touch waste with our hands. However, while earlier we had to fight for gloves, raincoats, gumboots, today, we have to fight for PPE kits.” This despite having to handle hospital waste, as well as contact care for affected patients.

What particularly rankled all ranks of sanitation workers was the undisguised class and caste bias among their authorities against taking even elementary steps to secure their safety. When the second wave raged, Delhi Chief Minister’s office tweeted, “Doctors are on the frontlines of the battle against coronavirus. All doctors serving in Delhi government’s Lok Nayak Hospital and GB Pant Hospital on Covid-19 duty will now be housed in Hotel Lalit.”

On similar lines, the Uttar Pradesh government temporarily requisitioned four five-star hotels – Hyatt Regency, Lemon Tree, The Piccadily and Fairfield by Marriott – to house doctors. In Mumbai, Taj Hotel, Colaba and Taj Lands’ End, Bandra were opened for doctors. But there was no thought for the sanitation workers, whose lives were at risk each day of their work, and yet they returned to their crowded shanties, exposing their families unknowingly to the infection. A sanitation worker in Dharavi, Mumbai, tested positive for the coronavirus, passed on the infection to his wife, who died.

Even in normal times in India, trash is not segregated – everything is mixed and put in one bag. As Kumhare observed, “Many a time, sanitation workers encounter sanitary pads, expired medicines and broken glasses in trash bags.”

“Lack of protective gear makes sanitation work difficult during normal times,” he told The Wire. “During a pandemic, these factors make them far more susceptible to the virus”.

The Bio-Medical Waste Management Rules, 2016 do lay down guidelines for some protection, for “for handling, treatment, and safe disposal of waste generated during treatment, diagnosis and quarantine of confirmed or suspected Covid-19 patients”. For instance, the guidelines prescribe that such contaminated trash “should be collected separately in yellow-coloured bags and handed over to authorised waste collectors engaged by urban local bodies”.

This waste collected separately in yellow-coloured bags is required to be transported in a truck designated to pick up Covid waste and then sent to an incineration plant. The one for Delhi, for instance, is in Bawana, where it is claimed that the infected waste is disposed of scientifically.

But in reality, reports came in of illegal dumping of masks and medical waste used for treatment and containment of coronavirus from across the country. Face masks were routinely thrown with household garbage and were being picked up by waste pickers unknowingly.

The Indian Express visited, for instance, a migrant workers camp in Delhi’s Sharan Vihar, and found frighteningly “rows of medical waste such as surgical masks, gloves, syringes, tunics, gowns and empty tablet packets, among other items, stuffed inside blue bags”. In this migrant camp live many medical waste collectors.

They collected trash from hospitals and brought this to their camp to sort, unaware or unmindful of the considerable risks this posed to themselves and to their neighbours. Dr Jugal Kishore, head of the Public Health Department at Delhi’s Vardhman Mahavir Medical College and Safdarjung Hospital claimed that bigger hospitals were taking all precautions but the ones outside cities and in periphery areas have poor waste compliance.

“There is no doubt about the great work that doctors, nurses and the police are doing in these tough times,” declared Dadarao Patekar, Sanitation Worker, Vice President of Kachra Vahtuk Shramik Sangh in Mumbai. “They are the frontline workers. So are we. The safai kaamgaar [sanitation workers] are working to keep India clean, thus safe.”

“But there is one difference,” said Patekar. “Doctors, nurses, police [personnel] have people from all communities and religions – across class and caste. Safai Kaamgaar are Dalits. How many upper-caste people do you see carrying waste or human faeces? We have never had any facilities – nor provisions”.

He continued gloomily, “We are the invisible workforce that keeps your cities and hospitals clean. This work is nobody’s first choice.”

“We are in this because of historical injustices, and we are stuck in this because we have no other means to feed our families,” he said. “We are born in such a life – we will die in such a life, with no one to question on our behalf.”

I append here a small anecdotal account of the response of Delhi authorities when our family was infected in the autumn of 2020. The infection first caught all the members of my daughter’s household (she, her partner and her three-year-old son who lived in Vasant Vihar, Delhi, with her partner’s parents).

A few officials visited their home once and instructed them to isolate themselves and to segregate their waste. They were given a yellow bag for medical waste. But no one visited them after that to monitor compliance, replace the yellow bags or extend counsel.

They also used the purple seal often found in government offices to stamp the hands above the wrist of every member of the household. They said, “This would mark you as infected if you broke your isolation and went out, for instance, to the market”. A couple of hours after they left, each of them went to the basin to wash their hands for lunch. To their surprise, the purple seal just dissolved in the soap and water and disappeared.

The virus caught up with my entire household a month later. But this time, not a single official visited or contacted us. I got my first call from any official five weeks after the infection. “Just checking,” the voice on the other side of the phone said to me cheerily, “would you like to donate your plasma?”

Read the other parts of the “Tsunami of suffering” series here.

Harsh Mander is a Richard von Weizsacker Fellow, Chairperson of the Centre for Equity Studies and convenes the Karwan e Mohabbat, a people’s campaign to fight hate crime with solidarity and atonement.