Indian community health care workers take on climate and health education

Whenever Anuja Mallewadi, 22, felt weak and desired to rest, the older women in her house yelled at her. She said her grandmother-in-law would say “When I was pregnant, I worked for over 12 hours a day on the farm and even walked several kilometers, yet nothing happened to me.” But that was in the early 1960s; today, the climate in Mallewadi’s village, Arjunwad, in India’s Maharashtra state, has changed tremendously, severely affecting her health. The unbearable heat took a toll on her well-being as the temperatures soared to 42 degrees Celsius this May. But the older woman in her house didn’t listen or let her rest during the day, forcing her to complete household tasks such as fetching water, cleaning floors, and cooking meals, all of which demanded physical labor. This left Mallewadi completely drained. She was prescribed bed rest as her hemoglobin levels fell below the normal range of 12-16 for pregnant women. “Even if she went outside for a few minutes, she felt sick,” shared community health care worker Shubhangi Kamble, referring to her poor health. “During pregnancy, many older women force the younger ones not to rest and share stories of how they had it much worse,” Kamble said. Traditional beliefs, compounded by the denial of climate shifts, often compel women to work strenuously despite the risks. This could have severe consequences for India, a country with the highest number of pregnancies and an average of 23 million children born each year. A study found that almost 50% of pregnancy cases in India are high-risk. Short birth spacing between pregnancies was a primary factor behind this. Other reasons include a higher prevalence of pregnancy-induced hypertension, anemia, poor nutrition, less maternal age, fewer weeks of the gestation period, preterm births, and adverse birth outcomes such as stillbirth and miscarriage. One such high-risk case was Mallewadi’s, where her workload exhausted her to the point where she started feeling depressed. That’s when she reached out to Kamble for help. Kamble is part of a network of over a million women community health care workers known as Accredited Social Health Activists, or ASHAs, appointed for every 1,000 people in India’s villages and towns. In the face of rising disasters, ASHAs are silently undertaking the task of educating communities on the health effects of climate change. Tackling climate misinformation August 2024 was reported as the hottest August on Earth in the 175-year climate record. In India, which witnessed grueling temperatures surpassing 50 degrees Celsius this year, the chances of heat waves are rising because of climate change. Soaring temperatures across India are severely affecting the health of pregnant women. Mallewadi puked often, felt dizzy, and was dehydrated this summer. While Kamble worked on these health ailments, she knew the problem was linked to climate change. So she started talking to the older women in Mallewadi’s house, but it wasn’t helpful. “They kept asking me who I was to intervene in their family matters,” Kamble shared, but she persisted, visited them often, and explained how extreme heat impacted the human body. During pregnancy, physiological changes make it difficult for the body to regulate temperature, leading to increased maternal core body temperature and pulse. This can result in fetal distress. Moreover, high temperatures are associated with gestational hypertension, preterm birth, gestational diabetes, and placental abruptions. Kamble would also explain that such conditions even impact newborns as they face a higher risk of low birth weight, birth defects, and higher chances of neonatal intensive care unit admissions. She also mentioned how Arjunwad witnessed higher temperatures and showed the health care department data. Kamble discussed the district’s heat stroke cases and the government’s advisory about staying indoors. “None of this mattered to them.” Kamble didn’t back down. She returned the next day, sharing cases from her community that highlighted the impact of heat waves on other pregnant women. She also pointed out easy-to-understand issues such as a rise in dehydration. “When you give examples from your community, people start trusting you.” After a month of conversations, she noticed changes, such as Mallewadi not being asked to complete all the household chores. However, Kamble wasn’t satisfied, as Mallewadi needed complete bed rest. She began sweating excessively and struggled to breathe, with no fan in the house to provide relief. Kamble spoke to the family members and suggested shifting her to her parental home in the neighboring Karnataka state, which had cooler weather. The grandmother and mother-in-law disapproved of this. Kamble warned that their negligence and unreasonable expectations could put Mallewadi’s life at risk. She would point out how ASHAs helped slash India’s maternal mortality rate by over 60%, from 248 per 100,000 live births in 2006 to 97 in 2020. “I was vocal that I can’t let anyone suffer in my community.” Finally, after a week of persisting, they agreed. “It was only because of her that my family understood shifting me was the right choice,” Mallewadi said. “Many people don’t understand the effects of climate change,” Kamble said. For them, climate change is just events such as floods, which cause physical damage. And explaining to people isn’t an easy job either. Often, ASHAs are yelled at for this, but they try not to lose patience. What makes it worse is the meager pay. ASHAs are considered volunteers and are paid an honorarium for the tasks completed. “We aren’t paid any extra amount for this duty of addressing climate misinformation,” Kamble said. Moreover, ASHAs in Maharashtra allege that they get an honorarium averaging around 4,000-6,000 Indian Rupees ($47-$71) monthly and are overburdened with several tasks, impacting their health. ASHAs have organized and staged several nonviolent protests in the past few years. However, their working conditions remain stifling. Despite this, Kamble has helped hundreds of pregnant women by sharing information on the health effects of climate change. Currently, she’s assisting 10 other pregnant women. Ronisa Mulla, an auxiliary nurse midwife from Maharashtra’s flood-affected Rajapur village, said, “ASHAs tirelessly combat misinformation and alert us to potential high-risk cases in advance.” She notes that this proactive approach has improved their preparedness, ensuring women’s safety. Tackling hypertensive disorders during pregnancy With rapid climate fluctuations, rising heat waves, and floods, ASHA Gayatri Khutale from Maharashtra’s Shiye village explains that most pregnant women are now prescribed bed rest from the fifth month. One such case was that of 27-year-old Priyanka Chougule. Like Mallewadi, she was pressured to work in the heat and not take a moment’s rest. “Many houses in the villages aren’t designed with the heat in mind, so it gets unbearably hot inside, especially in those made of tin,” Khutale explained. She was already suffering from anemia, and heat dehydrated her, impacting her blood pressure. What followed was tremendous backache, swelling in her legs, and a constant feeling of breathlessness. She was diagnosed with gestational hypertension in the third trimester and required immediate treatment. Khutale took her to a doctor and monitored her blood pressure weekly. Climate change is found to be leading to a rise in hypertensive disorders of pregnancy, or HDP, and many older people don’t trust this. “They say nothing happens in the heat.” Khutale started to explain that HDP remains the leading cause of maternal mortality. There’s a growing body of research that points to the link between climate change and hypertensive disorders of pregnancy. From 1990 to 2019, the HDP cases rose to over 18 million, the highest in South Asia. The World Health Organization found that it is responsible for 14% of maternal deaths globally. A study backed by the Indian government found that climate change led to gestational hypertension and preeclampsia. A review study published in the Journal of Medical Evidence found that 1 in 11 women suffers from pregnancy-induced hypertension in India. This can have several risks, women with HDP face a heightened risk of developing cardiovascular diseases within five years of delivery. Additionally, these women are at an increased risk of coronary artery disease. However, Chougule’s family didn’t trust this and Khutale’s words. Two days later, Chougule collapsed. Khutale took her to the primary health care center in the nearby village, which has a special heat ward, where she was administered iron sucrose intravenous drips. Looking at the rising complications, Khutale increased her visits. “I spoke with them patiently because only after their approval do you get a chance to meet the young pregnant women in the house,” she said of the rudimentary practices that continue today. When nothing else worked, Khutale began taking new mothers to share their experiences and how her suggestions had helped them. This finally proved to be the tipping point. By this time, eight months passed, but not all hope was lost. When Chougule went into labor, Khutale quickly rushed her to the hospital. “We managed to save both the child and the mother,” said Khutale, who feared a severe complication during childbirth. “The newborn was underweight, but we were able to save both.” Relieved by the safe delivery, the Chougule family finally thanked Khutale for helping to “open their eyes.” Disaster preparation A major challenge ASHAs face is the reluctance of older people to believe that a flood could inundate their village. Often, this has landed many pregnant women in problems as families don’t evacuate them till the last moment. This has even led to cases of infant mortality, perinatal depression, and complications in pregnancy, Kamble explained. To avoid this, ASHAs start counseling and debunking misinformation months in advance. “Three months before a flood can strike, we start asking families to look for an alternative place to live during the floods,” she said. While many families have begun listening to ASHAs, a few don’t. “This year, I stayed with my husband in the house despite the rising water levels to ensure the safety of pregnant women who had not been evacuated and arranged emergency rescue facilities for them,” Kamble said. Preparing in advance helped Kamble save Mallewadi’s life when Arjunwad witnessed another flood in July. “I was in touch with her [Kamble] over the phone and returned after the floodwater receded,” said Mallewadi, who is due to give birth in the next two months. Kamble’s timely intervention ensured Mallewadi was not just safe but wasn’t exposed to traumatic events, either. Mallewadi’s hemoglobin levels and health improved. Looking at such cases, ASHAs feel inspired to keep doing this work. “While this work requires a lot of patience, whenever I save a woman, I feel it’s worth all the efforts,” said Kamble with a wide grin.