Earlier this week, reports emerged that there have been 44 cases of suicide in Chitral this year alone, majority of which were women showing symptoms of clinical depression, but remained undiagnosed. In light of these staggering numbers, the health department of Khyber Pakhtunkhwa has mandated for a commission to be formed and assess the main causal factors and the lack of psychosocial support available to patients suffering from mental health illnesses.
Before the Mental Health Ordinance (MHO) of 2001, which has marginally (if at all) improved the management of, and service provision towards mental health, the law presiding was the Lunacy Act of 1912. The Lunacy Act was inherited by Pakistan after partition; the text of which had no specifics regarding consent and confidentiality, doctors were not required to inform patients or their guardians about the nature, effects, risks or costs of treatment, nor were they obliged to provide alternatives. Under the Lunacy Act, those deemed to be ‘lunatics’ were legally allowed to be detained for up to 30 days if permitted by the presiding magistrate, a clause which was repeatedly misused and exploited.
Even though the MHO has made substantial changes to the text of the law, its implementation was stagnant. Significant changes included additions of informed consent, confidentiality of identity, and a maximum of 72 hours detention during which a psychiatrist must examine the patient to start treatment. In addition, criminal offences were specified under the Ordinance that included penalties for those who willfully make false statements to discredit someone as mentally ill; for the incorrect treatment of patients at psychiatric facilities; and the ill treatment and/or exploitation of a mentally ill individual by members of the public at large. An important clause in the MHO required all blasphemy defendants to have a psychiatric assessment, in an effort to grant protections and curb the high number of mentally ill individuals that were being disproportionately victimized under the blasphemy laws for personal vendettas or simply to ‘remove’ the patient from the community.
A Federal Mental Health Authority was established under the MHO, to develop national standards of care for patients, and to work towards a code of practice for mental health care providers. However, the Authority lapsed in 2010 without achieving any significant progress. In the same year, the Sindh High Court instructed a lawyer to refer his client to a ‘psychiatrist under the Lunacy Act’, indicating that even those within the justice system were unaware of the MHO’s existence nine years after it was passed.
Definitions of what fall under the ambit of mental health in Pakistan remains unclear. The Lunacy Act spoke of patients as ‘idiots’ and referred to them as ‘criminal lunatics’, insinuating that those with mental health illnesses require punishment, not treatment. In 2016, the Supreme Court ruled that schizophrenia does not fall within its legal definition of mental disorders as it is ‘not a permanent disorder’, it is ‘recoverable’, and therefore does not fall under the legal definition of ’mental disorders’ – a statement that has been widely denounced by advocacy groups locally and internationally.
After the 18th amendment, health became a provincial subject in Pakistan. The Sindh Provincial Assembly took the lead and passed the Mental Health Act in 2013, with an aim to improve the delivery of mental health care and protect the rights of those diagnosed with mental health disabilities. The Punjab government enacted the Punjab Mental Health Act in 2014, without any consultations with mental health professionals or advocacy groups. The Act itself is almost identical to the 2001 Ordinance in text, and merely replaced the words ‘Federal Government’ with ‘Government’. At the time, Khyber Pakhtunkhwa and Baluchistan did not replace the Ordinance with a mental health act, despite the actions of their provincial counterparts and the high number of cases related to mental health pouring out of local communities.
Pakistan has one of the lowest patient-to-doctor ratios in mental health in the world. There are less than 400 trained psychiatrists nation-wide, which is approximately one psychiatrist per half-million people. Services for mental health is also stunted due to the lack of implementing mechanisms for relevant legislation, with only 2.4 per cent of the country’s annual expenditure going towards health, of which less than 2 percent is allocated for mental health specifically.
There continues to be no representation of mental health within the Ministry of Health hierarchy, and Pakistan remains unable to adequately capture the obstacles surround mental health service provision. There is no recognized authority either in policing or law or social welfare which psychiatrists can approach in cases of emergency. Apart from the government hospitals, there are a large number of private in-patient facilities that are not registered with the Social Welfare Agency or Health Directorate; which means that there is no governing body to place checks, balances and monitoring mechanisms on the treatment of patients. In the absence of meaningful mental health legislation, those suffering from mental health illnesses have no safeguards or protections within their own homes, within state institutions, or at facilities for service provision.
Published in the Daily Times on September 1, 2018