Trauma to triumph: ASHA helping women overcome depression in India

If Vandana Kolhe had not been irritated by the continuously buzzing phone, she would have died. “I picked up the call, and someone was speaking to me in an extremely calm voice,” she recalls. “I am far from you but just a second away on a call. Don’t cry,” she heard the stranger say. Kolhe stepped back and slowly began walking toward her hut in Lonhar village of India’s Maharashtra state. “I was about to attempt another suicide, but something stopped me,” she recalls the challenging moments from 2021. The calm voice on the phone was Accredited Social Health Activist, or ASHA, worker, Netradipa Patil. More than 197 million people in India suffer from mental disorders, almost three times the population of the United Kingdom. This includes over 45 million people with depressive disorders. Women in villages find it extremely difficult to access mental health care because of a patriarchal society, significantly fewer mental health care professionals, and unaffordable health care. In such circumstances, community health care workers, known as ASHA workers, who aren't professional mental health care providers, help women recover from trauma and depression by providing talk therapy. ASHA is a cadre of over a million all-women health care workers appointed for every 1,000 people across India. In 2006, the health ministry began appointing ASHA workers to bring down infant and maternal mortality rates and make public health care accessible. ASHAs are grouped in the same village and are responsible for over 70 health care tasks such as providing medicines for common ailments, counseling on childbirth, providing antenatal and postnatal care, and ensuring universal immunization. For the next 90 minutes, Kolhe, 40, coincidentally also an ASHA worker, cried on the call. There were moments of complete silence. Patil kept telling her that being an ASHA is one of the world’s most thankless jobs. She kept reminding Kolhe how she had saved several lives. “I told her that quitting wasn’t an option, given how far she had come since her appointment in 2009,” shared Patil. Until this call, Kolhe and Patil were strangers. They live 900 kilometers away from each other. Despite being a health care worker, Kolhe couldn’t access mental health care as there were no medical facilities in her remote village of 654 people. For a population of 1.3 billion, India has just 47 government-run mental hospitals and for every 10 million people, there are seven psychiatrists. India will take another 171 years to meet its requirement of 130,000 psychiatrists, according to a paper published in the Indian Journal of Psychiatry in 2019. Women from rural villages find it extremely difficult to access mental health care as most mental health professionals are in urban areas. To fix this, ASHA workers like Patil are going beyond their duty to help women overcome trauma and depression, for which they don’t charge any fee. They even help their own fellow health workers, like Kolhe. Since ASHAs live in the same community, they know everyone in the village. During their fieldwork, they get to know the patients who need help. In many cases, ASHAs like Patil also get referrals by word of mouth. Barefoot counselors Patil is also an activist and a union leader representing over 5,000 ASHA workers and has a vast network in several parts of India. One morning, a fellow ASHA spoke to her of Kolhe, who was suicidal. Immediately, Patil asked her to dial Kolhe, who didn’t answer her call seven times. Patil refused to give up. But annoyed by the constant ringing, Kolhe finally answered, and so began her slow recovery. On the call, Kolhe told Patil about the problems she faced at the workplace and several issues about her personal life as well. “Moreover, my payments are often delayed,” she says, making it difficult for her to make ends meet. Kolhe also alleges rampant casteism within the ranks. “During any vaccination camp, I am not allowed to enter the vaccination facility. Earlier, people wouldn’t even allow me to enter the village temple and public school because of my caste.” Patil knew it would take several months to help Kolhe. “At first, I would call Kolhe every four days, and then we started talking on the phone once a week,” shares Patil. During these conversations, Kolhe often said, “I don’t want to live anymore.” After building a bond of trust, Kolhe called Patil whenever she felt stressed. They would talk for almost an hour. During these calls, Patil reiterated: “Ending life was not an option. I assure you that I am with you no matter what.” For every negative incident Kolhe shared, Patil first listened to her without making any judgments and then started sharing positive stories, pushing Kolhe to change her mindset and fight back. Since then, Kolhe began standing up to injustice. To help her overcome depression, Patil even suggested meditation and mindfulness exercises. She would share inspirational stories, messages, and videos. Patil began seeing the first set of changes after six months of counseling over the phone. “Within a year, she completely healed from the trauma and is now fighting back against the ill-treatment,” says Patil with a wide grin. Talking about her virtual help, Kolhe said, “I don’t have any relatives. When none wanted to help me, she [Patil] stood by me like a mother and a sister.” Some 164,033 Indians died by suicide in 2021. India has lost over 1.6 million people to suicide since 2010, reaching an all-time high in 2021. Considering such rising numbers, Patil always thinks about why she became an ASHA. “I want to help people by making mental healthcare accessible.” Looking at the widespread problem, Patil knew she had to train more ASHAs. She taught them the basics of listening carefully, not making judgments, and building trust and empathy with the community women. Over the past seven years, she has trained over 100 ASHAs, who now provide listening services for free, helping thousands of impoverished women. Today, Patil gets calls from ASHAs from over 10 states who seek her advice and share their learnings. She has helped over 300 women recover from depression. Patil says she learned this from psychiatrists and psychologists and built a deeper understanding of counseling by helping people. “Also, I learned a lot of things from my experiences and reading several books on mental health,” she says. “Helping someone overcome trauma and depression is not a day’s job. It takes many months and years.” Not all days are inspiring for Patil, as she says she has to keep repeating the same things, yet changes aren’t visible. “At times, this does frustrate me, but I know healing takes a long time.” ASHAs also take the victims to mental health care professionals and help them until they recover completely. Currently, ASHA workers from the Western Maharashtra region say that they haven’t received any training from the government regarding providing mental health care. However, in 2021, India's Health Ministry developed a training manual on mental, neurological, and substance use disorders care for ASHA workers. Patil says that this manual will be implemented in her region to train ASHA workers in a few months. While she says this is a positive step, she sees potential problems. “Because of the existing workload, many ASHAs won’t be able to handle the additional task of providing mental healthcare. In many cases, ASHA themselves suffer from poor mental health and listening to people’s trauma can trigger and cause them more trauma.” Patil further adds that most of the time, ASHAs aren’t compensated. “There needs to be a clear conversation regarding how much the Government will pay ASHAs for providing mental healthcare. We can’t keep doing all the things for free.” While the efforts of ASHAs are yet to be formalized across India, there are initiatives from other countries that rely on a similar approach. For instance, Friendship Bench, a nongovernmental organization in Zimbabwe, recruits grandmothers who help people struggling with mental health. They are trained to provide cognitive behavioral therapy with a focus on problem-solving therapy. These talk therapies are given to people with mild to moderate levels of common mental health disorders, such as anxiety and depression. They have trained over 2,000 community health care workers, helping over 280,000 people. Overworked and exploited In 2022, the World Health Organization honored ASHA workers with the Global Health Leader Award, highlighting their work during the COVID-19 pandemic and how they reduced India’s maternal mortality rate. Despite their success, ASHAs aren’t considered full-time workers, keeping them away from the purview of labor rights. “ASHAs are just considered volunteers and are paid honorariums and incentives based on the tasks they complete,” says Patil. For antenatal care, an ASHA is paid 300 Indian rupees ($3.6). Patil says that ASHAs in Maharashtra average just $45-$72 per month, far lower than the state’s per capita income of $215, and the payments are often delayed. During the pandemic, ASHAs were the frontline health care workers monitoring patients’ health parameters to help contain its spread. For this deadly duty, they were paid just 40 cents per day. “Many ASHAs weren’t allowed to take an off for several months, neither were many given adequate N95 masks, hand sanitizers, and personal protective equipment kits,” says Patil. Moreover, their workload keeps increasing. With such difficult working conditions, ASHAs started unionizing. Today, several ASHA unions across the country are fighting for better working conditions. Helping women break free from conservative beliefs During her community visits, ASHA Chhaya Kamble, 42, from Maharashtra’s Ganeshwadi village, found something different about Rukmini Mane’s son. “He wasn’t treated properly by anyone around him,” she observed. Soon, Kamble discovered that Rukmini Mane — whose name Devex changed to protect her identity — was depressed. She also found that her son was diagnosed with an intellectual disability that slowed his brain’s growth. “Disabled people are name-called and abused even today,” shares Mane. Kamble suggested enrolling him in a school for children with learning disabilities. However, this was met with stiff resistance from Mane’s mother-in-law. “Many women in our village aren’t allowed to leave the house because of the patriarchal beliefs. I knew taking the child to a faraway school wouldn’t be permitted,” says Mane. Facing initial backlash from her mother-in-law, she gave up. But Kamble kept explaining to her how important it was to enroll the child. “I knew things wouldn’t change easily,” shares Kamble. Every few days she spoke to Mane, helping her muster courage. “Doing this work involves going against the conservative patriarchal beliefs, which isn’t easy.” This went on for six months, but finally, Mane convinced her mother-in-law. However, it required Mane to leave the house and drop her child at a faraway school, changing two public buses. “My mother-in-law wasn’t in favor of me stepping out of the house.” This resulted in daily tussles for several months. Often, Mane felt like giving up, but Kamble always listened to her problems and stood by. After a few months, the mother-in-law began seeing changes in her grandson and was convinced by what Mane had been saying. Since this success in 2021, she has been regularly stepping out, ensuring that her son doesn’t drop out and is treated with respect. “I could intervene because I knew the family since 2009,” says Kamble. Now the Mane family is grateful to Kamble for her work and recognizes the child’s development. “She guided me at the right time,” thanks Mane. Before Kamble's intervention, Mane often struggled to share her plight and bore it alone. “Since I wasn't allowed to go out, I had no friends,” she says. Dealing with this for 15 years, she was lonely and had accepted that things wouldn’t change. “She was sick and depressed of such an orthodox atmosphere,” shares Kamble. This is not just Mane’s story. Kamble, who has also helped victims of domestic violence recover from trauma, says, “Not many women share their plight.” It is evident from the 2019-21 National Family Health Survey, which found that just 14% of women who experienced physical or sexual violence sought help. While Mane says she didn’t experience violence, it took many years for her to start sharing her problems. “Today, I am confident and ready to face all the challenges,” says Mane. Like her, today, thousands of women who once faced oppression and exploitation live better lives because of a sisterhood movement created by ASHA workers. Regarding what keeps her going, Patil always recalls Kolhe’s words, “I was about to end my life, but you not just gave me a new life, but taught me how to live it.”