Fits and Starts


Waiting for their turn

By Zubeida Mustafa

According to experts from WHO, nearly one out of ten people in Pakistan suffer from mental illness at one stage or another in their lives. It is estimated that 14 million people in the country and 1.2 million in Karachi need psychiatric attention. There are only 200 psychiatrists and 3500 hospital beds to take care of these patients.

Appalling figures no doubt. They, however, do not tell the whole story. Since psychiatric conditions are not major killers they tend to be ignored. Yet the fact is that out of the ten leading causes of disability (in terms of the number of years lived with disability) five are psychiatric disorders. They are debilitating and account for a tenth of the disease burden in all societies.

The positive aspect is that there is greater understanding of mental illness in Pakistan today. Those affected by it are not generally made the object of ridicule. But that does not mean that people have learnt how to cope with the pain, the agony and the trauma mental illness causes. These emotions continue to be suffered in silence.

Who has not had an encounter with a mentally ill person at one stage or another in life? There was Christine, a young student who was schizophrenic. She had to be hospitalized when she became unmanageable. She believed that people were haunting her. When she could stand it no more she committed suicide in the bloom of youth.

Then there was the seemingly normal man who was nameless as far as society was concerned. He would somehow manage to enter a girls’ college regularly and undress himself in public view of the young female students much to their shock and horror. As he would be led away by an angry chowkidiar, he would derive a thrill from the reaction he caused.

There is the case of the highly intelligent professional who appeared to be mentally quite sound but his paranoia drove him to extremes until he could not cope with even minor crises. His genius and profound knowledge of philosophy and poetry notwithstanding, he buckled under the stress and strain of day-to-day living until he wreaked havoc on himself and his family.

The most ubiquitous are the ones suffering from depression, the so-called common cold of psychiatry. They are the least known of all because many of them tend to hide in their own cocoon of misery. If untreated they become economically unproductive.

Worse still is the plight of the victims of psychosomatic disorders — problems induced by stress which manifests itself as diseases with seemingly organic causes. Such people suffer interminably because their cases escape diagnosis and they run from pillar to post, spending thousands on investigation and diagnostic procedures and treatment of their symptoms without obtaining relief.

Such are the tragic tales one hears again and again of people suffering from mental illness. Denied the sense of wellbeing which is the essence of mental health, many of them paradoxically end up spreading a lot of misery all around them. For decades their problems were compounded by the lack of social awareness, ignorance and the stigma that was attached to mental illness. It was the dreaded disorder no one wanted to talk about.

In some respects the situation has not improved even today. A visit to many of the shrines of saints can be an eye-opening experience. There one is a silent witness to the plight of a staggering number of mentally ill. Many of them are even left chained at the mazaar in the hope of divine deliverance which never comes. No better off are the sufferers who are thrown at the mercy of the so-called hakeems or faith healers who declare them possessed by demons and proceed to treat them accordingly. The patients have to submit to physical beatings in the belief that thus their tormentors will be driven away.

The more enlightened among them have begun to seek psychiatric assistance. They flock to the public hospitals which have facilities for the treatment of mental disorders. How much care can they get? A consultant said he would end up seeing as many as forty patients in a morning in the OPD at the Jinnah Post Graduate Medical Centre. That means a patient on an average gets a five-minute session with the psychiatrist in a public sector hospital. The more affluent go to the private practitioners and hospitals where crowding might be less but still enough to render the interaction they have with their counsellor quite inadequate. The situation has become bleaker in Karachi where violence, crime and lack of basic civic amenities have emerged as a new stress factor.

In this bleak situation the newly established Institute of Behavioral Sciences (IBS) comes as a ray of hope on the dark horizon. Set up by the Pakistan Association of Mental Health (PAMH), the Institute is not designed to be just another psychiatric hospital. The IBS promises to be much more. It hopes to become the nucleus of a comprehensive and integrated mental health service (both curative and preventive) which is something quite unheard of in Pakistan.

Prof. Haroon Ahmed, President of the PAMH, who is the driving force behind this project and its honorary secretary, believes that it is just not possible to cope with the incidence of mental illness in the conventional way. Pakistan cannot afford it.’

Take Karachi’s case, he explains. At least 1.2 million people suffer from major psychiatric disorders. Add to this number another two million who suffer from stress-related disorders and you have a sizable population in need of professional care. What are the facilities available? About 50 psychiatrists and 250 beds. If you really want to extend a helping hand, you need at least another 1000 beds with adequate equipment and trained professionals just for this megapolis. This is too large an order for a developing country with limited resources to even aspire for. Lahore’s demands would be no less. It is a major city, where everyday life brings similar stresses in its wake.

“We want to tap the family support and community goodwill which is available in our society and culture but which has not  been explored so far,” Professor Haroon says.

He points to the community- based care of the seriously mentally ill which has been tried in some other countries. This approach has been found to be feasible, more effective and humane. The patients recover faster, relapses are fewer and families are more satisfied. Moreover, it facilitates rehabilitation and integration of the patient into the community.

Dr Haroon Ahmed feels this approach would make the goal of care of the mentally ill achievable in Pakistan. The patient would need initial diagnosis and consultation with the psychiatrist. He can then be looked after by his family and community with the active intervention and counselling of trained health workers. If this method is adopted, a team of a doctor and a social worker can look after 25 patients quite efficiently with the help of the families. All that is needed additionally is a walk-in facility to offer help and guidance to patients with chronic mental illness in an emergency and to serve as a support group for relatives.

There was a time when this concept would have appeared to be quite farfetched in our society. Care of the mentally ill by the community requires a level of public awareness which was totally missing in Pakistan. Decades of efforts by the PAMH to educate the people about mental illness is beginning to pay off. A woman who had brought her daughter suffering from severe depression to be treated at the IBS talked to me with a degree of enlightenment and knowledge about mental illness which would have been quite inconceivable in the past in a person of her background. She seemed to be moderately educated and her source of information was mostly the Urdu newspapers she read. I was amazed to find her fairly familiar with many terms used to describe mental disorders. A few years ago she would probably have rushed her daughter to a faith healer. Similarly, another woman I met there had a retarded child with her. She recognized the need for professional help for her son rather than a visit to a maulvi.

 If the IBS which has just made a beginning succeeds in implementing its plans of providing community-based health care to the mentally ill, it would be a major breakthrough in psychiatry in Pakistan.

Mental haven

Once you have crossed the campus and the Shaikh Zayed Islamic Centre on the main University road, you have to watch out for a sign of a yellow rising sun. There you turn left and a bumpy ride down the kachcha road for a kilometer or so brings you to the Institute of Behavioral Sciences. It seems to have sprung up overnight on six acres of land given by the Sindh government in the Ojha sanatorium premises. With the prefabricated structure donated by a philanthropist it took a few months to set up a few consulting rooms, a waiting hall, a library, a pharmacy, some office rooms, a kitchen, a store and a huge area to be used as a community centre.

Dr. Haroon Ahmed, the president of the Pakistan Association of Mental Health whose idea the Institute was, feels the premises are sufficient to get started with. They can grow as they go along – and more importantly as the donations come in. “We will be busy very soon, “Dr. Haroon adds confidently.

Since August, a team of six consultants (one every day) have been organising out-patient clinics in the morning. The psychiatrist in-charge, Dr. Quader Ahmar, is available at the institute the whole day. The consultants’ services are honorary though a fee of Rs.200 is charged from the patients to recover the cost of the facility and to make it an economically viable concern. Those who cannot afford to pay, however, are given concessional rates or not charged anything at all.

When it is completed, the Institute will have 76 beds out of which 12 will be for children. The crisis intervention centre will serve as the emergency while a separate unit will treat victims of torture and violence. With its focus on community health, the Institute will ultimately have teams of psychiatrists and social workers to provide home-based care to patients in the catchment area (which is Gulshan-i-Iqbal and Gulistan-i-Johar).

Equally interesting and significant will be the research function of the Institute. The neat brochure produced to introduce the Institute promises to conduct research on some critical issues. These probably have never been  investigated seriously in Pakistan. Among others, they include spiritual values and shared beliefs and their influence on individuals and society; the traditional place of elders and the pressures of joint families; religious beliefs and practices and their role in mental health; stress and rising aspirations of women; urbanisation and environmental pollution and mental health; insecurity, and absence of social responsibility.

These factors have a direct bearing on the mental health of a person and the behavior of individuals. In this way the IBS hopes to expand its sphere of activity in a big way. Given the number of patients who have already started to come in, it seems the IBS will be pretty busy right away. – Zubeida Mustafa.

Source: Dawn 30 October 1997

Source: Dawn 30 October 1997