Caring for the mentally ill

By Zubeida Mustafa
Source: Dawn

THE health sector has traditionally received Cinderella-like treatment from the policymakers in Pakistan. In this scheme of things, it is not surprising that mental health has been relegated to the lowest rung of the ladder, if for no other reason than that it is the most misunderstood branch of health science. It is also the most stigmatised.

Thanks to the efforts of the Pakistan Association for Mental Health and some committed psychiatrists, a measure of awareness has been created about mental illness in the country. But this is confined to the patients’, their families’ and the caregivers’ level. As a result, a large number of people suffering from a mental disorders who would previously visit pirs and mazars are now turning towards medical practitioners to seek treatment. But attitudes of the public have yet to change because no campaign on a massive scale has been undertaken to educate people about mental health and illness.

Unfortunately the government which can make the greatest impact by intervening in a timely manners, has been slow in responding to the changing situation. For decades the Lunacy Act of 1912, an obsolete law in the context of the changed medical approach to mental illness, provided the legal and social framework for the practice of psychiatry. Persistent reminders that it was no longer politically correct to refer to the mentally ill as a “lunatic” who should be locked up by the police in ‘charya wards’ of jails, produced some results. In February 2001, after being in the works for 20 years, the Mental Health Ordinance (MHO) was promulgated by the government. This ordinance repealed the Lunacy Act.

The MHO was widely hailed in medical circles, some basic flaws in the ordinance notwithstanding. At least the first step towards change had been taken. But five years later, when the MHO is still a dead letter as it has not been implemented, disappointment has started to set in. It is frustrating to find that all the old undesirable practices continue to thrive as before. Until the machinery provided by the MHO is actually created and made operative, there is no hope for the mentally ill who are left to the tender mercies of the state.

Last week, the federal health minister and the health secretary who visited Karachi assured Dr Haroon Ahmed, the president of the PAMH who has been spearheading the movement for a change in the law, that they would look into the matter. One can only hope that they will treat the PAMH’s demand with a sense of urgency that the issue merits.

What is the MHO and why is it needed? The basic reason is that the changes that have taken place in the science of psychiatry after years of major research in the working of the human mind and discoveries in the pharmaceutical and diagnostic fields have not been reflected in the legal framework, health delivery system and social perceptions and behaviour in Pakistan. Significantly, professionals have been working to educate people about mental health and thus remove the stigma that mental illness carries. They have succeeded to some extent, as is evident from the growing level of awareness.

But the same cannot be said about the government’s role in the matter. Psychiatric services continue to be inadequate while the number of persons in need of help has grown phenomenally. It is estimated that 30-34 per cent of the population suffers from psychiatric/psychosomatic disorders at one time or another, with at least 1.5 million needing institutional care in the country. But Pakistan has only 5,000 beds for the mentally ill, and 40 per cent of these are in the private sector which is not always affordable for the poor.

While the government will have to address the issue of planning for mental health services and budgetary allocations, implementing the MHO requires political will more than anything else. It is now universally recognised that the mentally ill also have human rights which are grossly violated in our society because of ignorance and lack of compassion and humanism in the people dealing with them. The MHO is the only way to stop the old practice of the mentally ill being arrested and thrown into prison to be consigned to oblivion for ever because they are deemed a threat to society.

Under the MHO, a mental health authority is to be set up to advise the government on all matters relating to the promotion of mental health and developing new national standards for the care of patients and to improve mental health services. It is the regulatory body. It was set up in October 2001 and since then is supposedly working on the rules that have to be framed for its own functioning, the national standards and guidelines for diagnosis, care and treatment of psychiatric patients, procedures for the working of institutions and a code of ethics for psychiatrists. Nothing has come out of its labour so far.

The MHO also stipulates that boards of visitors will be appointed to carry out inspection of a psychiatric facility in its jurisdiction — this kind of monitoring is needed after one hears horrible tales of maltreatment being meted out to the mentally ill behind barred doors in some institutions. The MHO spells out in detail the guidelines to be observed if a person has to be admitted on an “involuntary” basis to a psychiatric facility and the rules governing his admission and discharge. No board has been appointed.

The ordinance requires district courts to be designated as the courts of protection and magistrates to be specially empowered to perform judicial functions assigned to them by the ordinance. Thus the court appoints the guardian of a “mentally disordered” person if one is required and the manager of his property to ensure that no violation of human rights takes place. Similarly, the magistrate is involved in the “involuntary admission” and discharge of a patient. Neither has any court of protection been designated nor any magistrate assigned the powers he is required to exercise under the MHO. As a result the ordinance remains a dead letter.

The law also provides for community based mental health services which offer many advantages, especially for those patients who can be looked after by their families at home. In keeping with modern concepts such services provide guidance, support and education to the caregivers, while rehabilitation and preventive measures are available to the patient on an informal basis. The existence of such services can be less disrupting for the patient and his family. They cost less to operate and can reach out to more people than institutional care.

What is delaying these actions by the government? It seems to be nothing more than apathy and indifference which the provincial health departments and the federal ministry of health are notorious for. It would be a pity if after coming so far the government were to abandon its quest for a new approach to mental health.