"You won't be able to identify me as I am not wearing the pink saree."
While trying to locate Lakshmi (name changed for privacy) - ASHA (Accredited Social Health Activist) assigned for Bapu Nagar, she remarked over the phone, "You won't be able to identify me as I am not wearing the pink saree."
When we met in person, she explained, "I am not wearing the uniform saree because I feel too hot in it, hence I am wearing a cotton saree."
It seemed like a casual remark, but it pointed to something deeper—how frontline health workers like Lakshmi are quietly adapting to extreme heat while continuing to keep public health systems running.
ASHAs are the backbone of India's public health network. Under the National Health Mission (NHM), each ASHA typically serves around 2,500 urban residents in Karnataka.
Their work involves far more than just health education: they walk door to door for household surveys, assist at Urban Primary Health Centres (UPHCs), support childbirths, organise community meetings, and maintain detailed health records.
In short, their work is everywhere—and mostly on foot.
When we visited Bapu Nagar, a low-income settlement in Kalaburagi, to explore the impacts of heat in the settlement, what emerged was an urgent and often overlooked reality:
Those responsible for delivering health services at the community level are themselves facing the brunt of climate-related health risks.
Kalaburagi, situated in the Northern part of Karnataka, experiences prolonged periods of extreme heat, with annual maximum temperatures averaging 44.9°C over the past seven years.
The district ranks among the most vulnerable in Karnataka according to the Heatwave Health Risk Index, driven by factors such as high diurnal temperature range, poor green cover, a large proportion of the population working outdoors, frequent heatwave occurrences, a high number of people with disabilities, and a significant proportion of individuals commuting to work on foot.
Due to walking around in the heat, my blood pressure dropped. I was given iron supplements at the UPHC, and only then did my blood pressure improve... I try to finish work by 3-4 pm, so I often skip lunch.
— Lakshmi, ASHA worker
For ASHAs like Lakshmi, heat exposure is an unavoidable part of the job.
Although this was her first major incident, she noted that colleagues frequently experience symptoms such as dizziness, fatigue, low hemoglobin levels, and body pain after prolonged exposure to the sun.
One of the factors contributing to their discomfort is the government-issued pink polyester saree—a mandatory uniform for ASHAs in Karnataka.
Polyester cloth lacks moisture absorption properties and traps sweat, exacerbating heat stress.
The saree material is like 'chhattri batti' (umbrella cloth). It feels like plastic. It causes discomfort, especially during the summers.
— Lakshmi
Despite repeated pleas to improve the quality of their uniforms, there has been little response from the authorities. Lakshmi shared, "We asked them to change the quality of the saree, but they did not respond. Even if we wear a cotton saree, we must wear the same colour. I tried to find a cotton saree in the same shade but couldn't."
While the material of the saree causes discomfort, the uniform holds significance for ASHAs, providing them with a visible identity in the community. Lakshmi noted, "Only if I wear this saree, people identify me as an ASHA. Without it, they might not take me seriously."
Furthermore, ASHAs have no fixed work hours. They are often summoned at odd hours to accompany women to hospitals for childbirth. "Sometimes we don't even get a chair to sit on in the hospitals. It gets very tiring," Lakshmi said.
Long hours on foot, exposure to high temperatures, and lack of rest all add up to significant strain. Yet, there is little institutional recognition of their occupational risks or provisions for heat adaptation—such as shaded rest areas, hydration breaks, or climate-sensitive clothing.
In January 2024, ASHAs across Karnataka, including Lakshmi, participated in a state-wide protest demanding better wages, timely payments, and improved working conditions. Among their demands was a request to replace sarees with more practical attire, such as cotton aprons, like those provided to ASHAs in Delhi.
Lakshmi noted that multiple letters were written to the state and central governments, but no response has been received to date.
In the absence of official support, ASHAs rely on personal coping mechanisms. "I sometimes use a scarf," Lakshmi said. "I cannot carry an umbrella with me. It's difficult to hold an umbrella and write at the same time."
These practices reflect their determination but also underline the lack of systemic adaptation measures for frontline workers facing extreme heat.
The experiences of Lakshmi and her colleagues reveal significant gaps in occupational health and safety for community health workers. Despite being central to India's health outreach, ASHAs are rarely included in discussions around climate-related occupational stress.
Strengthening the response requires:
As temperatures rise and heatwaves become more frequent, the resilience of frontline health workers will shape the resilience of the health system itself.
Protecting ASHAs is not only about ensuring their comfort—it is about occupational justice, dignity at work, and the long-term sustainability of community health systems. If those who form the first line of response are themselves at risk, the foundations of public health become fragile. Recognising and addressing their lived experiences is essential to building equitable, climate-resilient health systems for the future.
