October 10 was World Mental Health Day and the occasion provided health professionals with an opportunity to draw attention to this very crucial area of human well-being. This is a subject many do not want to talk about, so strong is the stigma attached to it.
Yet it has relevance for the lives of a large number of people. Research shows that nearly 10 per cent of the population suffers from mental illness at one stage or another in life. Given the insecurity and conflict that grip Pakistan today, it is likely that the ‘burden of mental disorders’, to use the World Health Organisation’s terminology, is greater in the country than is believed to be.
This year the theme selected by the World Federation for Mental Health was the integration of mental health into primary care. Among the reasons listed for advocating this strategy was its cost-effectiveness, the close link between mental and physical health and, above all, the human rights dimension of mental illness.
It is the last aspect that makes state intervention so essential in the matter. The issue is not simply one of healthcare being a basic right of the citizens. It is the need to strike a delicate balance. On the one hand are the rights of a person who suffers from a mental disorder and is not well enough to take care of himself. On the other are the rights of a community which may become vulnerable to violence or violation of its dignity by the presence in its midst of a person suffering from a mental disorder.
Since policymakers and people generally had no understanding of the significance of this aspect of mental illness, Pakistan remained saddled with an obsolete law, the Lunacy Act of 1912, for 54 years after independence.
As its nomenclature indicates, this law betrayed a total lack of understanding of mental illness. Patients were not perceived as having any rights. If they were prone to violence, they were treated as criminals and locked up in prisons in what were derogatively termed ‘charya wards’. An attempt to commit suicide was considered a crime and could land an ill person in jail.
Mercifully we have compassionate health professionals still in our society who have a profound understanding of the implications of not having a modern law on mental health and have devoted their life to having one adopted. It was the persistence and commitment of psychiatrists such as Dr Haroon Ahmed, the president of the Pakistan Association for Mental Health (PAMH) who has spearheaded the awareness-raising campaign that ultimately prompted the government to promulgate the Mental Health Ordinance (MHO) in February 2001.
The ordinance received a great deal of input from mental health professionals as well as legal minds, such as the late Justice Sabihuddin Ahmed, who so willingly took up public health causes and as a lawyer helped draft the mental health law. It is therefore a pity that eight years after its promulgation the MHO remains a dead letter. The fact is that to be implemented the ordinance needs further action that has not really been forthcoming wholeheartedly.
Dr Rubeena Kidwai, a clinical psychologist and secretary of the MHO task force of the PAMH, has a point when she observes that no law can be implemented without a mechanism. She identifies four institutions provided for by the MHO that are essential to make the law effective.
They are the Federal Mental Health Authority (FMHA), provincial boards of visitors, courts of protection and judicial magistrates. The FMHA is to serve as an advisory body and also to frame rules to enable its various functions to be performed. The first FMHA to be appointed did virtually nothing in its four-year tenure that ended in 2005.
Persistent reminders, recourse to the Sindh High Court by the PAMH and an order by the court that the government take measures to implement the ordinance within three months pushed the authorities into action. A new FMHA has been constituted, a letter from the health ministry in July informed the PAMH. But until now the members of this body have not been notified.
The fate of the other bodies has been no different. Sindh and Balochistan appointed their boards of visitors in October 2007 to inspect psychiatric facilities and make recommendations.
Given the low budgetary allocations for mental health and with no regulatory body to report to, the board in Sindh could perform minimally. Its tenure of two years expires later this month. What next? The courts and magistrates have not been assigned to handle the legal aspects and so they can be expected to keep matters on hold — indefinitely.
Considering this tardy performance of the government can any change really be expected in the mental healthcare scene in Pakistan? Soon after the MHO was promulgated the PAMH was energised and proceeded to hold workshops and gather all stakeholders on one platform to generate the momentum to get the MHO implemented. That momentum now seems to be dying down. Apart from the seminar held every year on World Mental Health Day, there is no public reminder that the MHO lies dormant. The letters PAMH keeps sending to the federal health ministry apparently stir no one.
A visible constraint, apart from the government’s apathy and lack of commitment, is the lack of coordinated efforts by the stakeholders. The psychiatric community in Pakistan is a small one and said to number barely 400. But it is grouped into a number of professional bodies and does not always work in unison. Were its members to get together and exert pressure collectively the government would be forced to respond.
Another restraining factor is the stigma attached to mental illness. There are few people who are willing to stand up for the mentally ill. As such there appear to be few stakeholders. With mental health shrouded in privacy who will champion its cause?
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