ISLAMABAD — A decade ago, world-renowned psychiatrist and medical anthropologist Arthur Kleinman termed the standard of mental healthcare across the world a ‘failure of humanity’. He noted that the worse deficiencies of care lay in the ‘local conditions’ faced by the mentally ill, and not the fact that mental disorders contributed to 15 per cent of the burden of global disease; or that less than 1percent of the health budget was dedicated to mental healthcare in developing countries; or that there is a severe dearth of psychiatrists in the latter.
The increased vulnerability of sufferers of mental disorders owes in part to their inability to use the full potential of their mental and emotional capacities. It also owes to their being unduly marginalized because of poor awareness of disorders, and the shame and stigma that follow. Patients with mental illness are thus rendered powerless, and unable to defend their interests.
The foremost right of the mentally ill is access to treatment. In Pakistan, psychiatrists are not just few and far between, they are also concentrated in urban clusters. At best, districts have one or two specialists. It is not uncommon for a family to travel from Balochistan to Karachi, or from the Northern Areas to Islamabad, to seek medical help. A family can spend thousands of rupees on travel for a single consultation. Given the skewed ratio of patients to specialists, consultations are brief, expensive and long awaited. More often than not, there are serious questions about the scientific and ethical aspects of mental health practices in terms of diagnostic and therapeutic skills.
There are multiple accounts of maltreatment or gross medical neglect in outpatient and inpatient facilities, whether in the government or private sector. Perhaps the most prevalent concern is that hundreds of patients are seen every day in a span of five to 10 minutes — a practice widely defended on the grounds that nobody should be denied consultation.
In developed healthcare systems, the minimum time allocated for a new psychiatric assessment is 45 minutes. Harm is likely to be caused if scientific limits are not observed. Furthermore, irrational and harmful poly-pharmacy prescriptions are rampant in both public and private clinics.
Another clinical practice is the frequent treatment of young women, mostly those with dissociative disorders, who are not fully aware of their state or surroundings. They are either forced to smell ‘ammonia’ (a repugnant chemical) to become more communicative or they are confronted, sometimes brutally. The most violating clinical example, even in some tertiary-care centers, is that electro-convulsive therapy (misleadingly known as ‘electric shocks’) is administered without general anesthesia, causing not only immense agony to the patient, but also discrediting an effective and sometimes lifesaving treatment.
The malpractice is not limited to psychiatrists; there are numerous examples of psychologists offering therapies without basic training, or prescribing psychotropic medications. Human rights concerns therefore extend to poorly trained mental health professionals pursuing unregulated practices, and not just a dearth of equitable resources.
Another fundamental right of patients with mental disorders is that they be treated in humane and non-abusive environments. This is especially important in the case of the most vulnerable: children with learning disabilities; women experiencing chronic schizophrenia; men suffering from drug dependence; and elderly persons with dementia. Abuse can range from sexual abuse of children in the community, brutal detoxification techniques in drug centers and violence against women, to harassment by law enforcers, atrocious rituals for exorcism and mindless incarceration in asylums.
Like everyone else, people suffering from mental disorders are entitled to avail all opportunities to live full personal, social and occupational lives. This essentially means that the state has to ensure educational facilities for children with learning disabilities, vocational rehabilitation for young people with mental disorders, housing and employment and access to healthcare. It must also facilitate all matters relating to criminal and civil justice. Widespread stigma and discrimination lead to misconceptions that people with mental disorders cannot be trusted, or lack the capacity to fully comprehend or make sound decisions. As a result, they face rejection and isolation when it comes to integration in their communities.
Mental health-related disabilities are a major concern for Pakistan. If we take the family members of sufferers with disabilities into account, disability affects up to 25pc of our population. Most disability is preventable, when common causes include infectious diseases (meningitis, tuberculosis, polio, HIV/AIDS), trauma or accidents (primarily road accidents), congenital and non-infectious diseases (such as epilepsy), perinatal injury (eg cerebral palsy) and malnutrition. Needless to say, lack of preventive and rehabilitative measures for those suffering from mental disabilities is a gross neglect of their human rights.
Even more significant for Pakistan is the fact that the vulnerability of people with mental disorders, or those at risk, escalates following humanitarian crisis (natural or manmade disaster, post-conflict or terrorism, or mass displacements). For the longest time, it has been assumed that basic needs include food, clothing and shelter only. Emotional support and connecting them to the relevant agencies — components of ‘psychological first aid’ — need to be recognized as undeniable rights. Their capacity to advocate for their rights or assert their needs is already compromised. Unless actively encouraged, these people might not even queue up for freely distributed rations.
These are just a few of the major violations of human rights where stakeholders across the board must engage to initiate systemic reform through comprehensive mental health legislation. Nationwide awareness campaigns are needed to dispel ignorance surrounding mental health. Capacity-building measures are urgently needed at all tiers of mental healthcare. Scientific protocols and guidelines developed for a local Pakistan-specific context are desperately needed. The subject of medical ethics must be formally integrated in medical training. In addition, mental health and psychosocial support should be an integral component of all initiatives following a disaster. Finally, clinical practices and relevant services must be regulated at all levels. Human rights demand it.
The writer, Asma Humayun, is a consultant psychiatrist.