Asha’s response to COVID-19: Providing care to slum communities in India

Slum populations, the most vulnerable to COVID-19, are emerging as hotspots for transmission of the virus. Comprehensive strategies for addressing this challenge exist, but reports of effective models for implementing them have been lacking. Asha, a 33year old health and community development organization in Delhi, India has responded to the pandemic by activating well-developed networks in the community to enact a range of interventions with encouraging results. The success of Asha in controlling COVID-19 in the slums reflects the realization of the values Asha promotes in the community: dignity, empowerment, justice, non-violence, compassion, gratitude, generosity, optimism, joy, and simplicity. Although developed by a team of Christians and those of other faiths on Asha’s staff, these values enjoy broad-based support within a pluralistic, Hindu-influenced society.


Introduction
Nowhere are the needs for holistic solutions greater than for the estimated one billion slum dwellers worldwide who are vulnerable to the effects of disease, poverty, and despair, live on land that does not belong to them in constant fear of eviction, and are surrounded by substance abuse, domestic violence, garbage, and political corruption. 1 Recognizing that slums are emerging hotspots for viral transmission, the WHO and the World Bank have called for phased, integrated, multisectoral support to slums. 2,3,4 Recommended short-term strategies emphasize health, community engagement and communications; social protection, jobs, and institutional support; leveraging data for transparency, monitoring, and response; and access to basic services and adequate housing. Recently, others have highlighted the potential for community health workers to improve health care utilization and outcomes in a cost-effective manner through the implementation of evidence-based approaches. 5 Despite a growing literature on the challenges presented for slum dwellers by the pandemic, few models for implementing these comprehensive strategies exist.
Delhi has a population of 21.75 million and its slums 4 million, in a country which recently surpassed 7 million cases of COVID-19. 6 It is also Nov 2020. Christian Journal for Global Health 7(4) home to Asha (which means hope), 7 a community health and development NGO set up 33 years ago by Dr. Kiran Martin, an Indian paediatrician. Around 700,000 people in 91 slum colonies of Delhi now benefit from the work of Asha. The Asha team is comprised of 87 dedicated personnel and are assisted by around 1000 women and 1500 young people from the slums who volunteer in their communities.

The Effect of COVID-19
On 24th March 2020, the Government of India overnight shut down the country in an attempt to curb the spread of COVID-19. This had an immediate catastrophic impact on those living in the slums. The poorest of the poor, these people were mostly dependent on daily wage work to survive. No work in the community meant no money and the possibility of starvation within days. In some of the Asha slums, there was a substantial migration because everyone lost jobs. The migration had other effects such as mental stress in the slum dwellers who decided to stay on. How would they survive? If they decided to go away, theirs was also an uncertain future. The Asha team continuously counselled the families to stay put. Ignorance and fear of COVID-19 was also rampant. Because of the population density, social distancing was impossible. While the Government subsequently set up "feeding stations," these were on the outskirts of the slums and were largely inaccessible to the weakest in the slums. The Asha team knew they had to react immediately to stave off a humanitarian disaster in slum dwellers at higher risk because they were unable to socially distance, lacked access to masks and water for washing, and needed education in behavioral practices to lessen their exposure to COVID-19. (Figure 1)

Asha's Immediate Response
Within days, the Asha team -• Activated existing, well developed networks in the slums and set up "Teams of Corona Warriors." These teams were mostly staffed by some 300 young volunteers of university and high schoolers whom Asha had known for years and whose education they had supported. • Trained the volunteers and tasked them to immediately start educating each of their local communities about COVID-19 and assessing local needs of the most vulnerable. • Prioritized the most vulnerable -elderly, disabled, chronically ill, pregnant women, and children under 5. • Provided basic groceries and cash for basic essential needs -cooking gas, medicine, and grinding grain for families in Asha slums not under quarantine who had no money left with them, to the very poor, elderly, disabled, and people with chronic illnesses ( Figure 2). In some slums, the ration was distributed to the whole community, but in other slums, the ration was given to 50% of the families. • Educated everyone they contacted regarding COVID-19 and how to act to reduce risk. • Formed liaisons with the local police to protect rather than control and intimidate the people and with local sanitation workers to maintain toilet blocks and remove garbage. • Developed supply chains and logistics, based on existing relationships, to obtain and distribute some key supplies -soap, disinfectant, PPE, food, grain, vaccines, medicines, and sanitary supplies. • Provided consolation and comfort to ensure mental health well-being. Warriors gave their mobile numbers to the elderly, handicapped, chronically ill, and most vulnerable. The access to warriors served as a hotline around the clock, especially in emergencies. The warriors also visited slum dwellers experiencing depression, anxiety, and loneliness, and provided social, mental, and emotional support to overcome the uncertainty arising out of the circumstances. • Continued to address essential ongoing needs that had potential long term catastrophic consequences -antenatal, natal, postnatal care; vaccinations (including against typhoid as temps rose into the 100's); ongoing treatment of chronic diseases; assistance for students leaving schools and university students who had no access to computers but needed to take exams; special nutritional programs for those under 5 and adults with critically low BMI, developed in conjunction with dietary experts in UK and US.
• Held special health care clinics for pregnant women, children under 5 years, patients with chronic illnesses, and for geriatric patients. • Because of COVID-19, special ongoing programs for malnutrition were developed. For children under 5, Asha provided a high-calorie, high protein Laddoo (sphere-shaped sweet) along with vitamins and other supplements. To malnourished women and adolescent girls, a nutritious drink rich in calories and protein was provided along with iron and vitamin supplements. (Figure 3) Asha works among approximately 700,000 slum dwellers. The Asha team and warriors went to every house and lane to educate regarding COVID-19 and screened using infrared thermometers and pulse oximeters. If they found a person having flulike symptoms, they immediately referred them to the nearest COVID-19 testing centre. Individuals who tested positive were assessed for clinical conditions, the severity of illness, and comorbidities. The Asha teams referred the patients with suggestive symptoms to designated testing centers in government hospitals, community clinics, and to mobile clinics. The COVID-19 tests were and are being done free of charge, paid for by the government of Delhi.
The government health workers also conducted physical assessments to ensure adequate facilities for home isolation so that clusters of cases did not develop. If an adequate facility for home isolation was found, the patients were put into home quarantine. The patients were given medicines and Nov 2020. Christian Journal for Global Health 7(4) monitored regularly through phone calls and oximeters. Patients with co-morbidities or severe symptoms were immediately admitted to COVID-19 designated hospitals. Homes of patients were quarantined for a minimum of 14 days and a poster put on the main door. Contact tracing was done by the government, and all family members and neighbors were tested.
The Asha teams and warriors spread awareness in the community about the presence of a COVID-19 positive case and encouraged the slum dwellers to avoid that lane or area. They also kept in touch with the patient and the family member through phone calls, gave emotional support, and ensured proper sanitation of the area by the municipal corporation. Areas where six or more people were tested positive for coronavirus were identified as "hotspots" or "containment zones" in order to recognize their probability of a high degree of viral spread. Strict movement restrictions were put in place in such areas to prevent further spread of the virus, and deliveries of essential items like groceries, medicines, and dairy products were made by government authorized delivery personnel only. The Asha team ensured that the area was restricted, and that slum residents stayed away from that zone. Figure 4 illustrates how primary prevention, such as that provided by Asha, reduced the need for health care to alleviate problems and the need to intervene with treatment.

Discussion
People living in the slums are the most vulnerable population in the world and have been the most affected during the COVID-19 pandemic. 1 Only a few reports describe attempts to implement strategic interventions recommended by the WHO, World Bank, and others. 8,9 In one report, four social workers recognized food insecurity within the slum area of Jabalpur, India and partnered with NGO's to provide ration kits to some 900 families and, subsequently, worked to connect needy slum dwellers to a government protection program for vulnerable people. 8 Another described the effectiveness of several interventions in the Dharavi, Mumbai, Asia's largest urban slum of 1 million people, where a model termed "chasing the virus" was used in contrast to waiting for people to report it. After discovering a first case, the municipal corporation closed the slum cluster entrance and exit, disinfected public toilets, began door to door screening, worked with private doctors to initiate containment strategies, and partnered with NGOs to build trust and provide food. In April, Dharavi had 491 COVID-19 cases with a 12% growth rate. After the implementation of public health measures, in May the growth rate was 4.3% and in June only 1.02%. Case doubling time also improved to 43 days in May and 78 days in June. 9 The infection rate of .04% in Asha slums is comparable to the .05% rate reported in Mumbai, though Asha does not have figures showing the growth rate.
The success achieved by the multi-pronged approach taken by Asha in preventing morbidity and mortality, while alleviating financial stress is similarly worth noting with the hope that lessons Nov 2020. Christian Journal for Global Health 7(4) learned from these practices could make countries more effective in future pandemics. 10

Conclusion
Key factors that enabled a quick response were that Asha: • is a long established, locally based and led organization with a long history in the communities it serves. • has strong, involved, local leadership that cares deeply for the people they are serving, is well connected to them and is working from a longarticulated value base of dignity, empowerment, justice, non-violence, compassion, gratitude, optimism, joy, and simplicity.
• has well established supply networks in Delhi and committed supporters around the world. • is small enough to be nimble and personal but large enough to serve 700,000 people. • recognizes that, even under the pressure to address immediate need, it is equally essential to address longer term values as Central to Asha's Approach The success of Asha in controlling COVID-19 in the slums also reflects the realization of the values Asha promotes in the community: dignity, empowerment, justice, non-violence, compassion, gratitude, generosity, optimism, joy, and simplicity. We believe that these were demonstrated by its staff and volunteers who risked their own health to combat the humanitarian crisis of COVID-19.
Although developed by a team of Christians and those of other faiths on Dr. Martin's staff, Asha values are contextualized and live comfortably in Hindu influenced society -neither simply restating local culture, nor foreign and hostile to it. By embodying values that respect the dignity of every person, Asha is respected in pluralistic and non-Christian contexts. Asha's values are holistic, comprehensive, and used to inform decisions, for example, about whether a financial program would result in empowerment. Taught, modeled, and discussed constantly, the values live in the work and not in a manual.
As the pandemic in India continues to grow with about 75,000 recorded cases being added daily, 6 Asha's 33 years of experience in refining and implementing its values-based approach has much to teach those working to help impoverished, multifaith communities at risk.