When Discomfort Becomes Duty: ASHAs Under Heat Stress  
 

Across India, over a million Accredited Social Health Activists (ASHAs) serve as the backbone of the public health system. They connect households to clinics, ensure maternal and child care, and mobilize community response during epidemics and pandemics. Increasingly, they are also becoming the face of climate-health action, helping families prepare for heatwaves, floods, and associated disease outbreaks. Yet while they protect others from rising temperatures, their own exposure remains largely unacknowledged.

By the time she steps out of her home, the sun is already high and the air feels heavy. Her morning has already been full with cooking for the family and getting children ready for school, but her real work is just beginning. Around 10 a.m., she starts her rounds, walking from house to house in the sun knocking on doors, checking blood pressure, counselling expectant mothers. She wipes the sweat from her brow and keeps moving, calculating whether to spend money on an auto or walk to the next home. She knows that heat slows her down, but when asked how it affects her health, she dismisses it, as if discomfort is just part of the job.

This story reflects what many ASHAs  have told us. Transitions Research spoke to ASHA workers from Gujarat and Punjab to understand how heat affects them and their work. Their routines were similar: walking door to door for hours, because private transport is unaffordable, and public transport is rarely accessible where they work. They work outdoors through the day, with no protective gear, no rest spaces, and no safety measures from the government. Their income is incentive-based, irregular, and rarely reflects the amount of physical labour they put in. There are no fixed working hours, and even protests and strikes have brought little change.

But when we asked specifically about heat, their responses shifted. They spoke about tiredness, lack of transport, delayed payments, but not about how the heat harms their own bodies. It was not denial, it simply did not register as a health risk to themselves. Most said, “it’s not a big deal…. we manage.” The discomfort was felt, but absorbed into the routine of their work.

The reality, however, is far from routine. Long hours in high temperatures push the body beyond safe limits. Core temperature rises, leading to heat exhaustion or even stroke. Repeated dehydration and heat stress are medically linked to kidney injury and, over time, chronic kidney disease. The National Disaster Management Authority notes that extreme heat, combined with pressure to meet targets, increases stress and anxiety, forcing workers to keep going despite fatigue. Gender also shapes risk, women sweat less than men under the same conditions, which can make it harder for their bodies to cool down. Medical evidence from hot regions shows serious harm. A study in Tamil Nadu found that women working in high heat had nearly twice the risk of miscarriage compared to those in cooler conditions. One ASHA worker in Mumbai, aged 42, said constant exposure to heat left her unusually irritable and mentally drained, something she linked to menopause and rising temperatures.

So while ASHAs may not describe heat as a serious risk to themselves, scientific evidence shows otherwise, the strain is real, only hidden beneath what they’ve come to accept as everyday discomfort.

During field visits, symptoms like dehydration, dizziness and exhaustion are common. In Haryana, where land surface temperatures now reach 47°C, a HeatWatch survey found that 68% of ASHA workers reported dehydration and 67% reported exhaustion, while nearly one in four had experienced heatstroke. Yet these signs are not treated as dangers, but as expected parts of work. What remains unseen is the long-term damage. Heat does not announce its harm immediately, it accumulates silently. Most ASHAs only spoke of sweating, tiredness or thirst. The deeper health risks are either unknown to them or not considered important enough to document and adapt against. The invisibility doesn’t stop at the body, it extends across the system. Despite their role, heat rarely features at the supervisory level, in daily briefings or work planning..

A 42-year-old ASHA worker from Punjab and a 49-year-old from Gujarat, live hundreds of kilometres apart but share the same story. Neither has received official support to cope with heat, and neither expects it. Both come from economically weaker backgrounds, where every visit brings a small but vital payment. For them, skipping work to escape the heat is not an option. The conversation on health ends where survival begins. 

On paper, official guidelines suggest ASHAs should work only three to four hours a day, four days a week. In reality, over 73% spend more than six hours outdoors daily, while most of them working 12-15 hours, often through peak afternoon heat. Incentive-based pay means any missed work directly reduces earnings, which usually totals less than ₹10,000 a month. 

Their responsibilities are not just financial. Their emotional connection to their community runs deep. As one ASHA put it, “I still go for field visits because there’s a mother waiting for me”. In rural India, Community Health Centres are expected to have specialists like an obstetrician–gynaecologist and a paediatrician, but there’s a 80% national shortfall including 74% fewer OB-GYNs and 82% fewer paediatricians than required. In most villages, there is simply no specialist to call, which is why ASHAs become the only reliable link to care. When they fall ill, there is no replacement. The system absorbs the delay silently. As one health official said, “ASHAs work with the most vulnerable families who don’t know when to visit hospitals or what to feed their children. Without them, these women are left alone.”

Further, the system also expects them to shoulder emerging risks, such as those brought by climate change. In Rajapur village of Maharashtra, an ASHA continued working during repeated floods, caring for pregnant women, warning families of rising water, and helping them move to safer areas. But what remains invisible is how climate impacts them. In this climate-health equation, they are counted only as service providers not as women who are also getting directly affected. This absence is visible in policy too. In Haryana’s Heat Action Plan, ASHAs are listed only as “messengers.” In states  like Tripura, Uttarakhand and Uttar Pradesh, they conduct awareness drives on heat but no guidelines exist for their own protection. Their exposure is neither recorded nor budgeted for.

So far, only a few initiatives recognise this issue directly. In Haryana, HeatWatch organised sessions on heat-related emergency care that were designed for both ASHA workers and the communities they serve. Unlike most trainings that focus only on community awareness, these sessions also directly addressed ASHAs’ own health, symptoms of heat stress, and basic steps for self-protection during fieldwork. Many ASHAs said this was the first time a session included their well-being, rather than focusing only on the community’s. It showed that when ASHAs are given information about protecting themselves, they begin to see heat as something that affects their bodies too, not just a condition they work in. Even so, such efforts remain limited. Most states still lack heat safety protocols, rest breaks, shaded spaces, protective gear or financial support for ASHAs working in high heat.

So the question remains, who protects the women protecting everyone else? Protecting ASHA workers from heat is not only a matter of labour rights, it is central to India’s public health resilience. A workforce that is exhausted and unprotected cannot sustain community trust or health outcomes. To make heat visible is to acknowledge that endurance is not protection. It is to recognize that the women who safeguard community health deserve the same safeguards, water, rest breaks, training, protective kits and respect.