Anguish of living

“DEATH is what men want when the anguish of living is more than they can bear.”
— Euripides, Hecuba (c.425 BC)

In the past month, three reports of suicides have shocked the country. The first was that of Bushra Bibi who with her two young children threw herself in front of an oncoming train. The second was that of a young student at the prestigious LUMS institute in Lahore.

He hanged himself in his hostel room. The third case was that of a man in Karachi who also hanged himself as he was being pursued by the bank for defaulting on a loan. Poverty was stated as the reason in the first case and academic difficulties in the second.

The three tragic incidents highlight the multifaceted aspects of the baffling phenomenon of suicide which is on the rise in Pakistan. According to the Edhi Foundation, four to five cases of suicide are now being reported across the country daily compared to the daily average of two to three last year.

Globally, approximately one million people commit suicide annually; almost 85 per cent of them in developing countries. While suicide rates (per 100,000 population) are highest in European countries including Lithuania, Estonia, Russia and Hungary, the actual number of people who kill themselves is highest in China (almost 300,000) and India (110,000).

For every suicide, there are at least 10 to 20 attempts at suicide. The World Health Organisation (WHO) estimates that by year 2020, about 1.5 million people will kill themselves worldwide every year. Traditionally, suicide rates are low in Islamic countries compared to non-Islamic ones.

Suicide is a complex phenomenon where biological, psychological, social and personal factors come together at a certain point in time to make a person vulnerable to suicidal behaviour. Suicide does not happen in a vacuum. Before taking one’s own life, a person passes through a ‘suicidal process’ during which he/she crosses many ‘thresholds of protection’. These may include religious and social factors, family obligations, responsibility of children, legal prohibitions, etc.

However, once the individual passes through these protective barriers he/she reaches a ‘point of no return’. At that point, nothing matters to him/her — neither religion nor family obligations, nor the effect of suicide on others. His/her anguish is so great that death is seen as the only way out of his/her predicament. The duration of the suicidal process usually takes weeks (maybe months) rather than hours or a few days.

In recent years, the public health perspective of suicide has gained importance as a majority of people committing suicide are under 30 years. The productive years of life lost (YLL) is much more as compared to those who commit suicide when they are older. This is a huge loss to society.

Studies conducted in different countries show conclusively that mental illness is associated with the vast majority of suicides. Of these, clinical depression is the most common mental disorder, implicated in 80 to 100 per cent of cases. Hence early recognition and treatment of depression has the potential to prevent the majority of suicides.

Broadly, the causative factors of suicide can be divided into distal and proximal factors. Distal factors include socio-economic conditions, poverty, unemployment, the law and order situation and the inability to get recourse to justice, while proximal factors include adverse life events such as failure in exams, argument with a significant other, loss of job, refusal of marriage to person of choice, etc.

Both are necessary for suicide to take place. Distal factors provide the groundwork on which proximal factors act. Many reports highlight only the more proximal factors. People don’t kill themselves just because someone scolded them or they failed an exam. In most cases, they had already entered the ‘suicidal process’ and the event proved the final tipping point.

What is the situation in Pakistan? Under the Pakistan Penal Code, suicide and attempted suicide are considered illegal acts. Attempted suicide is punishable with a jail term and heavy financial penalty. While prosecution for a failed suicide attempt is rare, harassment of the victim and his/her family is not uncommon. Most people, therefore, try their best to conceal the act for fear of social stigma. There is, therefore, gross underreporting of cases of suicide and attempted suicide in the country.

While there are no official figures for suicides, in 2002 WHO estimated there were 15,696 suicides in the country. Research conducted at Aga Khan University shows the figure closer to 7,000 to 8,000 suicides every year. Another 70,000 to 150,000 people attempt suicide every year. Most of them are given medical treatment and sent home. The psychological factors that precipitated the act in the first place are hardly ever addressed.

Despite the strict prohibition in Islam, incidents of suicides have been increasing in Pakistan over the last few years. The most plausible explanation is that the fine balance between the protective influence of religion and socio-economic factors appears to have been disturbed in Pakistan.

Behind every suicide are shattered families who go through a range of emotions ranging from grief and shame to guilt, anger and despair as they try to come to grips with their loss. Many blame themselves for treating the victim harshly or not being sensitive enough to have picked up the signs earlier. Many family members become clinically depressed themselves. Postvention is the term used for the management of psychological reactions of those bereaved by suicide. It is a neglected area but one of utmost importance.

Daily reports of suicides in Pakistan show a serious public health problem that needs to be addressed on an urgent basis. There is need for social policies that are just, fair and equitable and will address the real needs of the people. Issues of poverty, unemployment, lack of health and education facilities and recourse to justice need to be addressed urgently. In Pakistan, these macro factors contribute to the high levels of stress and despair being experienced by our population.

There is also an urgent need to establish low-cost mental health facilities which are accessible to the poorer sections of society. All professional educational institutions must have psychological counsellors to deal with the psychological stress that students undergo. It is a sad indictment of our society that while we can pay lakhs of rupees to a singer to entertain our formation commanders or spend the amount on lavish weddings, we cannot find the money to address the mental health issues of our population.

All three recent suicides were unnecessary and preventable. As a society we bear collective responsibility for the tragedies. Let not the deaths of the three brave but desperate people (and countless others like them) whose anguish of living drove them to take their own lives prove to have been in vain. Their deaths should serve as a reminder that we need to redefine our national priorities. We owe it to their memory. n

The writer is professor of psychiatry at the Aga Khan University, Karachi.

muradmk@gmail.com

Hazardous road to democracy

IF the continuing impasse over the restoration of the judges dismissed through an admittedly illegal executive order six months ago is any guide, the present regime — with the persisting role of the president in statecraft — is likely to experience frequent turbulence on an undulating and as yet uncharted roadmap to democracy.

The journey is going to be even more uncomfortable for those on board — with a permanent fasten-your-seatbelt sign — as the two co-drivers of the vehicle do not share a clear vision about its destination, having been forced to steer it in rather unlikely circumstances.

Often, they seem to be behaving more like chauffeurs of rival rent-a-car companies than drivers of a public bus. To stretch the metaphor, the vehicle is in danger of being hijacked by personal and parochial agendas.

The ‘heavy mandate’ the coalition received from the electorate some 10 weeks ago is beginning to erode as the real problems of rising prices and falling incomes make life for nearly the majority of the population increasingly unbearable, as evidenced by the disturbing rise in suicide rates recently.

While the countdown on the judges’ restoration has become irrelevant, the more important and politically significant deadline of 100 days for achieving a wide-ranging agenda of economic and social goals promised by the prime minister in his inaugural parliamentary address is fast approaching. If significant progress is not made in that direction, the coalition could encounter a strong popular backlash of despondency and cynicism, which would only benefit its enemies.

A worrying aspect of the current situation is the increasing disconnect and dissonance between the political and economic elements of the coalition agenda and the assigned distribution of responsibilities among coalition partners. Ideally, both major partners in the coalition, the PPP and PML-N, should be jointly responsible for all aspects of their agenda. However, in practice there seems to be a broad division of responsibilities between the two.

While the government is officially being run by the prime minister with coalition partners as members in the cabinet, it seems that the major political decisions are being made by one person with the grudging acquiescence of another. Neither of the latter two are members of parliament, let alone the cabinet. This rather novel system of backseat driving is yet to prove its durability and usefulness.

Supposedly fashioned on India’s Sonia Gandhi model, it is a contraption which could easily come apart. It not only lacks the institutional underpinning that accounts for the greater stability, resilience and smoothness of the Indian contrivance, it also does not have the fit of charisma and competence which Sonia Gandhi and Manmohan Singh epitomise.

At the operational level, the distribution of portfolios at the centre has been made in a way that key economic and social ministries, such as finance, commerce and industry, communications, food and agriculture, petroleum and natural resources, education and science and technology have been allocated to PML-N nominees. Those considered to be ‘sensitive’ and ‘security-oriented’, such as defence, interior, foreign affairs and port and shipping have been retained by the PPP — reportedly on the insistence of the US which sees PML-N as a less trustworthy ally.

As the coalition was crafted with the negative aim of pre-empting political space to the Musharraf-led Q-League rump, it failed to focus on more substantive issues which were necessary to consolidate the alliance. The Charter of Democracy, which was restricted to constitutional and political reforms, did not envision a situation in which the two major allies would be working together to govern the country. It failed to spell out the details of a common minimum programme that would appeal to the constituents of both.

With the economic situation rapidly deteriorating and people desperately looking for a credible way to get out of this morass, the two parties must put their heads together and focus on such a programme. If the alliance is to succeed in providing the country with a stable democratic system sensitive to the needs of the poor, rather than the elite groups and their foreign patrons, it will need the glue of a populist, yet pragmatic, socio-economic renaissance.

The cumbersome political machine now in existence is also burdened with a pro-active role for the presidency, based on primarily foreign and military interests that have been its guiding source since its present incumbent took over, pulling it in the opposite direction or putting brakes on its momentum. It is increasingly clear that the incumbent will resist being marginalised to the role of a Fazal Elahi Chaudhry or a Rafiq Tarar or to having his wings clipped and being reconciled to live as a caged bird. Neither is he capable of playing the role of neutral umpire, being more prone to act as a coach and raise and train his favourite team.

The coalition is on the horns of a dilemma whether to remove what most consider to be the greatest stumbling block in its way or to concentrate on more substantive issues from which the latter distracts attention. The judges’ issue has taken too much time and energy of the coalition through second-guessing the presidency’s intentions. It may be worthwhile to call the latter’s bluff and face the consequences, rather than being paralysed by its fear; its worst fear may be the fear itself.

What Pakistani democracy needs most is not more experimentation but studious attention to the basic principles of democracy, such as transparency, participation, debate and dialogue, both within parliament and within political parties and a wider engagement with civil society.

The latter should including lawyers and other professional groups, the academia, think-tanks (which we don’t have enough of — those that exist don’t have either the quality or the autonomy to conduct innovative research), as well as NGOs (especially those which are not mere offshoots of foreign agendas).

The road to democracy needs to be paved solidly — and not merely with good intentions.

syed.naseem@aya.yale.edu

Culture of obedience

“CIVIL disobedience is not our problem. Our problem is civil obedience. Our problem is that numbers of people all over the world have obeyed the dictates of the leaders of their government and have gone to war, and millions have been killed because of this obedience. Our problem is that people are obedient all over the world in the face of poverty and starvation and stupidity, and war, and cruelty. Our problem is that people are obedient while the jails are full of petty thieves, and all the while the grand thieves are running and robbing the country. That’s our problem.” — Howard Zinn

The good-natured, simple people of Pakistan held their breath, anxiously counting each day of the 30-day ulti ginti, only to realise that they were being given a placebo intended to buy time, create new coalitions and support an illegal president. A realisation that those in power have little utility for the Nov 2 judiciary when they already have efficient PCO judges who can handle the decade-old cases in a matter of weeks.

After all, the PCO judges, best described by Faraz as “moazazin-i-adalat halaf uthaney ko, missal-i-sail-i-mubram nashista rah mein hein” have no qualms about NROs, real or fake degrees, legal or illegal presidents, constitution or no constitution and a host of other such minor aberrations. We are back to a new minus-12 deadline, yet another legal committee and far more dubious interpretations. Dubai and London are the two new capitals of Pakistan, where the unelected string pullers decide our fate.

Clearly, we are out of the frying pan and into the fire. The political parties have staged their arrival as a result of an ‘understanding’. They have so much extra baggage to carry, people to appease, an opportunity to whiten their messy pasts and a host of other considerations to multiply their pelf and power. The state machinery is being rapidly purged of unkey log and replaced by subservient apney log.

By doing this, we ensure the leftover demolition of the institutions and reinforcement of the concept of personal loyalties. An army chief could twice PCO our country precisely because the people heading our institutions have been reduced from custodians of the constitution to obsequious, personal obedient servants.Pakistan has paid a huge price for its culture of obedience. When on Nov 3, 2007, a military chief issued a PCO, threw away the constitution and removed the judges, how many amongst the ruling elite resisted the move, resigned in protest or refused to obey illegal orders? How come, except for 60 honourable judges, every minister, police commissioner, bureaucrat, ambassador, general, governor, vice chancellor or anyone who was anybody in Pakistan preferred to obey illegal orders instead of protecting the much ‘oath-taken’ constitution? Did they not know, what is known to every class five student, that the military chief’s action was a blatant violation and an act of treason?

Chief Justice Iftikhar Chaudhry may or may not be remembered for his judgments. He will, however, go down in history as the person who said ‘no’ to a dictator and set a new, much-needed tradition of ‘disobedience’. Pakistan has little chance of getting out of this quagmire, unless government officials, political leaders, military generals, police commissioners and others in a position of authority learn to say ‘no’ to orders that go against the constitution.

A good beginning would be for the military to hold accountable its own constitution-breaking general and the civil government to hold accountable all those who aided and obeyed the unconstitutional orders of Nov 3, 2007. Another good beginning could be to show the door to all those judges who made a beeline for the PCO oath, knowing well that a sitting seven-member court had set aside the illegal order. Surely those who think they can continue life by applying band-aids on society need to reconsider this first-aid approach, and go for more serious corrective and preventive actions.

We need to upgrade our constitution from a ceremonial (and often violated) oath-taking instrument to a practical document of daily use. It should be taught in every school and a copy given to every government employee. The annual confidential reports should evaluate employees on their ability to say ‘no’ to orders that are contrary to the constitution.

The National Disaster Management Cell should organise yearly emergency drills to prepare citizens and organisations to respond to unforeseen PCO disasters. Each country prepares and protects itself from its own potential calamities. For Pakistan, it is the PCO. We can make a new beginning only if we are willing to give up the ‘culture of obedience’, take preventive measures for the future and apply corrective actions for the disaster that befell us on November 3, 2007.

naeemsadiq@gmail.com