In early September, one of Pakistan’s most watched television news channels reported that Bilawal Bhutto Zardari, 27, the chairman of the prominent Pakistan Peoples Party (PPP), suffers from bipolar disorder. The report, presented during a show that prides itself on its serious investigative journalism could not be confirmed; some say it was planted by a political opponent. However, the irresponsible and sensational airing of the report created a social media storm, and within minutes Zardari was branded a “lunatic” and “psychopath,” “fit only for a madhouse.”
It was easy for viewers and the TV station to vilify the man: The stigma against mental illness is rampant in Pakistan. It is sustained by popular belief in spiritual cures — exorcising evil spirits, experimenting with herbal cures and reciting verses from the Quran — and a lack of awareness about mental illness’s causes, symptoms and cures.
But the Pakistani government also plays a large role in the continued stigmatization of mental illness. Before the 2001 Mental Health Ordinance (MHO), which has marginally improved the treatment and management of the mentally ill and their affairs, the law presiding over patients in need of psychiatric attention was the Lunacy Act (1912). If the name of the colonial-era law is already unfortunate, its contents had even more glaring problems. The text had no concept of informed consent for the patient — it was not necessary for doctors to inform patients or their guardians about the nature, effects, risks and costs of prescribed treatments or offer alternatives before carrying them out. It also called patients “idiots” and spoke of “criminal lunatics” — an oxymoron, given that a “lunatic” should be provided care and treatment, as opposed to punishment.
While the new ordinance is drastically better than its 1912 predecessor, it remains poorly implemented. In January 2010, almost nine years after the MHO was passed, the Sindh High Court instructed a lawyer to refer a client “to a psychiatrist under the Lunacy Act” — raising suspicions that lawyers, judges, policemen and patients had not been made aware that a new law even existed.
Another important factor to this legislation is how it deals with the criminal fallout of untreated mental illness. In order to meet international standards set by the World Health Organization, the MHO will have to make be amended to ensure that authorities will investigate the mental health of those under trial as well as those who have been convicted. To this end, the MHO should mandate mental health law workshops to educate members of the judiciary and the police.
It will be difficult to make much progress, given Pakistan’s current budget guidelines. Only 2.4 percent of Pakistan’s annual expenditure goes toward health, and out of that, a mere 2 percent is set aside for mental health. Nor is there reliable data on the prevalence of mental illness. One report suggests that there are 15 million people in the country who need attention from mental health practitioners. That’s 8 percent of the population. Another study states that mental illness afflicts 10 to 16 percent of the population. And then there are doctors who claim that about 40 percent of Pakistan’s 180 million residents suffer from common mental disorders.
By way of comparison, 18.2 percent of the U.S. adult population suffers from similar mental ailments, and in India the figure is 10 percent.
Pakistan has one of the lowest mental illness patient-to-doctor ratios in the world. In a seminar held earlier this year in Karachi, a prominent Pakistani doctor revealed that Pakistan has only 380 trained psychiatrists — meaning that there is roughly one psychiatrist available per half-million people. The result is that even when patients fighting something as common as depression or anxiety recognize their symptoms, overcome the stigma, gain the support of their families and start looking for medical help, there simply isn’t much help to be had.
Meanwhile, in the United States, any area where the ratio exceeds 30,000 people per psychiatrist is considered to have a shortage of mental health professionals. The United States isn’t exactly known for providing affordable health care to its citizens, but it’s still miles ahead of Pakistan; still, one of the reasons for shortages in the U.S. resembles Pakistan’s problems: Students are discouraged from specializing in psychiatry because, compared with other medical fields, it is seen as less prestigious and not as well compensated.
Many of Pakistan’s problems, from lack of education to public security, are alleviated with the support of local and international nonprofits. This absolves the government from failing to provide basic services to its people. Still, in the absence of a competent government, this stopgap system has some merits. The British BasicNeeds program, which began forming partnerships with Pakistani nonprofits in 2013, has already served 12,000 people in need of psychiatric attention. In addition to setting up camps where patients can see doctors, receive prescriptions for medicines and engage in therapy, the program trains citizens to recognize symptoms and side effects of mental illnesses.
The program is very cost effective, at $20 to $30 per person per year. If the government cannot reform its laws and invest in hospitals and doctors, then at the very least, programs such as this one can help Pakistanis get the treatment they need. And as awareness about mental diseases grows and people understand that chemical imbalances in the body can be alleviated with low-cost drugs, the stigma surrounding the diseases will also start fading away. According to a World Health Organization theory, the richer and older in age a society grows, the more likely it is to promote mental health. This is because societies with a large middle class put more resources into diagnosing and treating mental illness and older societies have more people with dementia, a form of mental illness.
More than half of Pakistan’s population is under the age of 25, so if this theory is correct, age will not spur much change. But 35 percent of the country is now considered middle class, and the numbers are rising every year.
One can only hope that with rising prosperity, Pakistan will begin to pay attention to the problems that lie beneath.