October 10 marks World Mental Health day, and in Pakistan it is an opportunity to draw attention to one of the most neglected issues regarding human well-being. Conservative estimates by researchers reveal that that at least 10 to 16 percent of the country’s total population (207.74 million) suffers from mild to moderate psychiatric illnesses. The majority of these sufferers are women.

Yet access to psychiatric services is sparse.

In Pakistan, there is one psychiatrist for every 10,000 persons suffering from a mental disorder. A study conducted by the World Health Organisation (WHO) in 2009 in collaboration with the government states that only five mental hospitals are available in the country. These are organisationally integrated with mental health outpatient facilities. In addition, there are 0.02 beds for persons with mental disorders in forensic inpatient units, and 1,620 beds in other residential facilities, such as homes for persons with mental retardation, detoxification inpatient facilities, homes for the destitute and others.

The prevalence of mental illness has increased with unemployment and political and economic uncertainty, which can only be addressed by tackling the associated causes in a wider perspective

More egregious is the availability of psychiatric care for children: there is only one child psychiatrist for every million children who suffer from mental health issues. There are 3,729 outpatient mental health facilities in the country, of which only one percent are for children and adolescents. Only 624 community-based psychiatric inpatient units are available in the country for a total of 1.926 beds per 100,000 population.

The reasons for psychological disorders vary from genetics to trauma and social injustices. Experts relate the rise of mental health problems to poverty, violence, economic problems, political upheavals, the lack of employment and under-employment, demanding work environments, gender inequity, unguided urbanisation and the loss of the old social order.

Early this year, while giving a presentation at the Karachi Arts Council, noted psychologist Dr Haroon Ahmed pointed out that there are two million people in Karachi alone who suffer from mental, emotional, intellectual or social adjustment disorders (stress or sadness, for example, caused by the inability to cope). Out of these, according to the Pakistan Association for Mental Health (PAMH), at least 0.3 million require urgent psychiatric/psychological attention. The figures are much higher than the national estimates and this makes Karachi a special case.

THE CASE OF KARACHI

For any serious analysis, the discourse on mental health and associated care needs to be grounded in discussions about the prevalent mode of production. The overarching consumerist culture we live in breeds dissatisfaction. The desire for more material products and the urge to substitute old products with new is pivotal in maintaining social standards. These induced demands make life a rat race and human relations — and states of mind — become the first casualty.

Fulfilling your materialistic desires through a life of assembly-line operations causes a loss of creative abilities. This, in turn, creates a sense of alienation and results in psychological deficits in an individual. The result is a society characterised by emptiness and isolation. With these inner contradictions between needs and induced wants becoming ever more evident, severe psychological disorders are sown.

Noted columnist and human rights activist I. A. Rehman writes in a column that, between 2007 and 2009, “Every second house in Karachi had one or more persons taking tranquillisers; every fourth house had a psychosomatic/psychiatric problem and masked depressive disorder; every tenth house had a patient needing psychiatric care for depression, psychosis, psychosomatic disorder, obsession, intellectual disability, epilepsy or drug dependence.”

In its peculiar political landscape, the residents of Karachi struggle to survive, facing inadequate civic amenities and unaffordable lifestyle expenses, coupled with unemployment. Rapid urbanisation and related issues increase the pressure to find peace in the metropolitan hubbub. To survive, Karachi needs four million new jobs after every five years, and the city is full of fresh and recent graduates waiting for job opportunities.

As is the case with major cities, Karachi is left at the mercy of ruthless market forces. By and large, development plans, infrastructure projects and economic decisions of the 1990s and 2000s remained insensitive to the requirements of the middle class and low-income groups, alienating the two income groups from development circuits and creating distrust among service providers/civic agencies.

To quote one example from a spectrum of worries, to obtain a house in the planned settlements is now a far cry for most people. The current price of a 240 square yards house in North Nazimabad exceeds 25 million rupees. The rent of the same size house varies from 40,000 rupees per month to 50,000 rupees per month.

The economic reforms of the current regime have resulted in making the survival cost twice as expensive, resulting in anxiety and anger at the household level, where monthly bills have often become unmanageable. Coupled with perennially rising commutation problems and with the current petrol price, there has been a sharp increase in travel costs as well. All this takes a toll on the leisure travels of Karachi’s residents, thus depriving a sizable population from outdoor relaxation and entertainment opportunities.

The social structure is also going through transformation. The earlier prevalent joint-family system which provided a strong protective network is vanishing fast: 89 percent of families in Karachi are now nuclear whereas in the 1989 Survey for the Development Plan 2000, the figure was only 54 percent.

WHAT NEEDS TO BE DONE?

In a capitalist society, the usual narrative in professional psychiatric practice and public awareness directly and indirectly supports the market in the form of pricey consultations and expensive medicines. That narrative needs to be rewritten and an integrated approach is needed to address the issue.

A comprehensive spatial mapping describing where mental health services are needed most and why, needs to be accomplished. Any healthcare cannot be considered universal if it excludes mental health. By advocating for allocating funding to integrate mental health into existing health and social protection programmes and protocols, countries stand to improve a range of outcomes—including for HIV, maternal and child health, non-communicable diseases, and disability. In the absence of investing in mental health care services, those sufferings from mental health issues, or their families, are forced to pay out of their pocket and for ineffective remedies such as vitamins, sedative herbs and, sometimes, even abusive forms of confinement in homes and at shrines. An advocacy strategy is needed to meet the agenda.

Though various stakeholders of the mental care circuit are engaged with the affected families to make the victims of mental health disorders fully functional human beings, the scale of the provided services is not enough to address the issue in a comprehensive manner. Disabling and life-threatening mental and neurological illnesses are mostly associated with economic issues. The majority of mental health costs are not only related to treatment. There are also indirect costs related to the lost productivity of affected individuals and their caregivers.

Evidence-based research is needed on the economic outcomes of mental health interventions and, inversely, on the mental health outcomes of economic interventions. This includes exploring the effects of poverty reduction programmes on the prevention of mental disorders. Comprehending mental healthcare comprehensively requires understanding the clinical as well as the social and economic consequences of the issue.

The above recommendations admittedly are at the operational level. They are not going to work unless the root causes of economic disparities are addressed through policy and legal frameworks of distributive justice. The challenge needs to be viewed through the prism of the wider economic struggle and resulting social inequalities, and the solution lies in making a call for social justice, economic equality, dignity and respect. Whether the decision makers will do it or not will have a bearing on the future generations.g

Mansoor Raza is a lecturer at the Development Studies Program, Department of Architecture and Planning at NED University of Engineering and Technology, Karachi. He can be reached at mansooraza@gmail.com

Published in Dawn, EOS, October 13th, 2019