Pakistan's forgotten patients

Samira Shackle reports on mental health provision in Pakistan – a nation failing to meet the needs o

“ECT [electro-convulsive therapy] is frequently administered unnecessarily or inappropriately, which can be life-threatening. It is not uncommon for nurses to literally chain patients to beds and leave them festering in urine-soaked sheets. Some workers in these facilities are doing the best they can, but many purporting to be psychiatrists are insufficiently qualified. Even in private hospitals, there is no regulation, so potentially dangerous cocktails of drugs can be prescribed. There is a shocking level of ignorance and moral suspicion of the mentally ill, even among those who work in the hospitals.”

This damning description of one of Pakistan’s state mental health facilities comes from a psychiatrist who asked to remain anonymous. A range of public figures spoke out against the government’s failure to provide mental healthcare on World Mental Health day last week, illustrating the tragedy of Pakistan's mentally ill.

According to human rights campaigners and mental health workers, the Pakistani government’s refusal to enact changes to mental health legislation constitutes a serious breach of human rights. The 2001 Mental Health Ordinance replaced the notorious 1912 Lunacy Act; updating the terminology surrounding mental illness, introducing rules to prevent mistreatment, and establishing the Federal Mental Health Authority.

But according to the Human Rights Commission of Pakistan (HRCP), and leading psychiatrists, the government has made no attempt to implement the vague aims of the ordinance. Despite guidelines by the World Health Organisation on the need for monitoring to protect against degradation, the Federal Mental Health Authority disbanded in 2005 - having met just once.

The HRCP unequivocally states that the seven year lag in implementing the Ordinance has prevented the mentally ill from accessing their rights, sentiments echoed by Supreme Court judge Justice Sabihuddin Ahmed, in a seminar to mark World Mental Health Day last week.

“Changes to the law have had absolutely no impact,” says Dr Murad Khan, professor of psychiatry at the Aga Khan University in Karachi. “It’s a positive step, but none of it has been acted upon. On the ground, people are treated in exactly the same way.”

Dr Ghaus Mohammad, chairman of the Sindh Board of Visitors, confirms this, explaining that his attempts to communicate with the federal health minister on reform strategies have failed to elicit any response.

These failures are matched by a dramatic rise in the number of suicides over the last decade. There are no official records, due in part to stigma which persists in a country where attempted suicide remains illegal. Research conducted by the Aga Khan University, however, estimated that there are between 6000 and 8000 suicides per year. The World Health Organisation puts the number closer to 15000.

“Suicide is vehemently condemned in Islam, so these figures show that Islam is losing its protective effect in Pakistan,” explains Khan. “The fine balance between religion and socio-economic factors has been disturbed by the political instability and bad social policy. We lack the strong political process needed to make positive change”.

The intense political instability of the region has been partially blamed for the mental health difficulties faced by its population. Estimated numbers of Common Mental Disorders (CMDs) such as depression and anxiety are among the highest in the developing world, confirmed by high sales of tranquilisers, sleeping tablets, and anti-depressants, all of which are available over the counter.

Of the estimated 1/3 of Pakistanis who live in poverty, the majority are uneducated and lack awareness about mental affliction - turning to spiritual healers first. However, because 90% of mental healthcare in Pakistan is private, even when people do wish to seek medical help, their options are severely limited. On average, it costs between 600-1500 rupees to see a psychiatrist - half the salary of a low-paid worker.

The state psychiatric facilities that do exist provide a limited help for the very poorest members of society. Horror stories about these facilities abound, and across both public and private sectors, there are just 4000 – 5000 beds in psychiatric wards, serving a population of well over 160 million.

The WHO’s International Covenant on Economic, Social and Cultural Rights (ICESCR) sets out the right to the highest attainable standard of physical and mental health. It sets obligations on states to make health services, including mental health services available, accessible, acceptable and of good quality.

But the Pakistani government is not signatory to this covenant. Spending on healthcare accounts for only 1% of the national budget, and just 0.4% of that is spent on mental health. Despite a tireless campaign for improvements, as Khan says, “We need more resources, more funding, more education. Until our crisis of governance is resolved, I don’t see how the situation will improve”.