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KARACHI, Pakistan — After the attack on the Army Public School in Peshawar last December, a volunteer team of psychologists and psychiatrists traveled there to provide psychological help to the survivors, most of whom were students. They were the first emergency medical workers responding to the trauma that the children, whether wounded or not, experienced. In their four-day assessment, they uncovered a complex picture of mental health damage that will affect the children, perhaps for the rest of their lives, as well as the parents, teachers, policemen and military officers who were at the scene.
Some survivors will inevitably join the 10 percent of Pakistanis who, according to the World Health Organization, suffer from some form of mental illness. Like the students, many Pakistanis display trauma from the violence that grips their country. This only magnifies tensions and anxieties with longer roots — difficult family conditions, lack of money or the everyday stress of uncertain access to water or electricity. In a country of 180 million people, only about 340 psychiatrists are working today — one for every 333,000 people. Those able to access modern mental health care are the lucky ones.
In Pakistani society, there is little understanding of mental illness, and a stigma against talking about it publicly. Many Pakistanis think the symptoms have a supernatural or religious cause — possession by spirits, or a curse or test from God. Some visit faith healers who promise to exorcise the offending spirits, or traditional healers selling herbal cures; others recite Quranic verses, hoping their spiritual power can bring them physical and mental health. If those strategies don’t work, they may consult a physician; only when that too has failed will they seek a psychiatrist. “We often don’t see people until they are in a very advanced stage of the disease,” says Rubeena Kidwai, a clinical psychologist in Islamabad.
In the violence of recent years, the need for adequate mental health care has become even more urgent. Pakistanis living in the tribal areas, where drone strikes have suddenly blown apart buildings and killed innocent victims alongside the intended targets, have increasingly suffered depression, anxiety and post-traumatic stress disorder. The insecurity of displacement affects thousands who have fled fighting in North Waziristan. Mian Iftikhar Hussain, a psychiatrist in the northern city of Peshawar, has reported a threefold increase in mental disorders in the region.
Pakistan has made some progress since it became independent in 1947. Then, it had only three psychiatric hospitals. By 2005, the country had 20 psychiatric wards in 20 medical colleges. A major factor in this gain was the Pakistan Association for Mental Health, a nongovernmental organization established by the eminent Karachi-based psychiatrist S. Haroon Ahmed.
For 20 years, the association has focused on raising awareness about mental illness, especially among the poor. Today it conducts awareness camps in Karachi’s slums and working-class neighborhoods; attendees learn the signs of mental illness, and people with symptoms are urged to seek psychiatric or psychological treatment at a clinic.
The message may be starting to come through. Ms. Kidwai, who has worked in the camps, says patient-to-patient referrals among low-income groups are high. “Once one person has gotten treatment, he will bring someone else from his mohalla,” she said, referring to Pakistan’s low-income neighborhoods. “They’re not shy about telling other people they’ve gotten help.” By contrast, she says, more affluent patients are more reluctant to discuss their treatment publicly.
But the psychiatric community knows that Pakistan must reform its mental health laws before it can truly change negative attitudes about mental illness. For most of the last century, the mentally ill were served by the Lunacy Act of 1912, an outdated British law that used terms like “lunatic” and “asylum” to describe mental health patients and the hospitals in which they were confined and treated under court orders. This cruel language reflected not just how poorly the law served the mentally ill, but also how callously they were handled by those charged with their care. “They were beaten, chained, punished, administered electroconvulsive therapy for no reason,” says Dr. Ahmed. “It was a real human rights violation.”
Dr. Ahmed and other association members drafted Pakistan’s Mental Health Ordinance to replace the Lunacy Act; it was signed into law in 2001. This law defined mental health by modern-day standards and reduced the number of days a mentally ill person could be detained. It was far from perfect — it had been severely watered down by parliamentary and judicial wrangling — but it was an improvement. Unfortunately, in 2010 a constitutional amendment that reduced presidential powers also separated the ordinance from national jurisdiction and consigned its implementation to provinces.
Dr. Ahmed and the association prepared amendments to the original ordinance, and in September 2013 the provincial assembly of Sindh — the southern province that includes Karachi — passed a new mental health bill that actually has improved upon the national bill. (People who attempt suicide — still a crime in Pakistan — now have the right to be seen by a psychiatrist before facing charges in court.) Meanwhile, legal protection for the mentally ill remains a big issue, particularly when people try to get relatives declared insane in order to seize their property. “We have a responsibility to protect the mentally ill,” says Dr. Ahmed. “They suffer sometimes silently, and sometimes violently.”
Punjab has followed suit with its own mental health bill, and there are hints that people jailed for blasphemy may receive medical examinations to determine their mental health — which would be a huge advance. Still, as violence from terrorism and war spreads from the Afghan border to Pakistan’s cities and towns — just last Tuesday, a suicide bombing in Lahore killed at least four people — the incidences of stress disorders and other mental illnesses will no doubt increase. The country can little afford to ignore the terrible individual pain, and the national malaise, that inadequate mental health care brings.
http://www.nytimes.com/2015/02/20/o...lly-ill.html?rref=collection/column/bina-shah
Some survivors will inevitably join the 10 percent of Pakistanis who, according to the World Health Organization, suffer from some form of mental illness. Like the students, many Pakistanis display trauma from the violence that grips their country. This only magnifies tensions and anxieties with longer roots — difficult family conditions, lack of money or the everyday stress of uncertain access to water or electricity. In a country of 180 million people, only about 340 psychiatrists are working today — one for every 333,000 people. Those able to access modern mental health care are the lucky ones.
In Pakistani society, there is little understanding of mental illness, and a stigma against talking about it publicly. Many Pakistanis think the symptoms have a supernatural or religious cause — possession by spirits, or a curse or test from God. Some visit faith healers who promise to exorcise the offending spirits, or traditional healers selling herbal cures; others recite Quranic verses, hoping their spiritual power can bring them physical and mental health. If those strategies don’t work, they may consult a physician; only when that too has failed will they seek a psychiatrist. “We often don’t see people until they are in a very advanced stage of the disease,” says Rubeena Kidwai, a clinical psychologist in Islamabad.
In the violence of recent years, the need for adequate mental health care has become even more urgent. Pakistanis living in the tribal areas, where drone strikes have suddenly blown apart buildings and killed innocent victims alongside the intended targets, have increasingly suffered depression, anxiety and post-traumatic stress disorder. The insecurity of displacement affects thousands who have fled fighting in North Waziristan. Mian Iftikhar Hussain, a psychiatrist in the northern city of Peshawar, has reported a threefold increase in mental disorders in the region.
Pakistan has made some progress since it became independent in 1947. Then, it had only three psychiatric hospitals. By 2005, the country had 20 psychiatric wards in 20 medical colleges. A major factor in this gain was the Pakistan Association for Mental Health, a nongovernmental organization established by the eminent Karachi-based psychiatrist S. Haroon Ahmed.
For 20 years, the association has focused on raising awareness about mental illness, especially among the poor. Today it conducts awareness camps in Karachi’s slums and working-class neighborhoods; attendees learn the signs of mental illness, and people with symptoms are urged to seek psychiatric or psychological treatment at a clinic.
The message may be starting to come through. Ms. Kidwai, who has worked in the camps, says patient-to-patient referrals among low-income groups are high. “Once one person has gotten treatment, he will bring someone else from his mohalla,” she said, referring to Pakistan’s low-income neighborhoods. “They’re not shy about telling other people they’ve gotten help.” By contrast, she says, more affluent patients are more reluctant to discuss their treatment publicly.
But the psychiatric community knows that Pakistan must reform its mental health laws before it can truly change negative attitudes about mental illness. For most of the last century, the mentally ill were served by the Lunacy Act of 1912, an outdated British law that used terms like “lunatic” and “asylum” to describe mental health patients and the hospitals in which they were confined and treated under court orders. This cruel language reflected not just how poorly the law served the mentally ill, but also how callously they were handled by those charged with their care. “They were beaten, chained, punished, administered electroconvulsive therapy for no reason,” says Dr. Ahmed. “It was a real human rights violation.”
Dr. Ahmed and other association members drafted Pakistan’s Mental Health Ordinance to replace the Lunacy Act; it was signed into law in 2001. This law defined mental health by modern-day standards and reduced the number of days a mentally ill person could be detained. It was far from perfect — it had been severely watered down by parliamentary and judicial wrangling — but it was an improvement. Unfortunately, in 2010 a constitutional amendment that reduced presidential powers also separated the ordinance from national jurisdiction and consigned its implementation to provinces.
Dr. Ahmed and the association prepared amendments to the original ordinance, and in September 2013 the provincial assembly of Sindh — the southern province that includes Karachi — passed a new mental health bill that actually has improved upon the national bill. (People who attempt suicide — still a crime in Pakistan — now have the right to be seen by a psychiatrist before facing charges in court.) Meanwhile, legal protection for the mentally ill remains a big issue, particularly when people try to get relatives declared insane in order to seize their property. “We have a responsibility to protect the mentally ill,” says Dr. Ahmed. “They suffer sometimes silently, and sometimes violently.”
Punjab has followed suit with its own mental health bill, and there are hints that people jailed for blasphemy may receive medical examinations to determine their mental health — which would be a huge advance. Still, as violence from terrorism and war spreads from the Afghan border to Pakistan’s cities and towns — just last Tuesday, a suicide bombing in Lahore killed at least four people — the incidences of stress disorders and other mental illnesses will no doubt increase. The country can little afford to ignore the terrible individual pain, and the national malaise, that inadequate mental health care brings.
http://www.nytimes.com/2015/02/20/o...lly-ill.html?rref=collection/column/bina-shah
