Prof. Dr. Muhammad Iqbal Afridi, President Pakistan Psychiatric Society (PPS) lauded the directives by Justice Salahuddin Panhwar of Sindh High Court (the petition filed by Ms. Erum Shaheen, submitted through her counsel, Mohammad Qadir Khan), to all the commissioners and the senior superintendents of police to constitute special committees to visit public places including shrines and graveyards across the province for finding patients with mental health issues, and referring them to the Sindh Mental Health Authority for proper care and treatment. These public places are considered sanctuaries and feasible alternative treatment for impoverished families of the mentally ill individuals, as most mental illness often remain unacknowledged and commonly ridiculed and stigmatized by the society. Most of the patients found in such places are suffering from diagnosable and treatable mental conditions.
The highlighting of the purpose of Section 19 of Sindh Mental Health Act 2013, and ensuring its explanation to all police officials that if the same was exploited, it would expose the guilty to the legal action and such an action must be a bona fide one, is noteworthy and protective.
Justice Panhwar’s observation that Chapter IX (Section 54) of the Sindh Mental Health Act also provided for the inspection of prisoners with mental disorder and ordered all the district and sessions` judges to ensure during their visits to prisons that all such inmates to be referred to the authority is highly significant, as imprisonment harms mental health.
Overcrowding (a serious problem, e.g. Landhi Prison capacity for 1700 but holding 5000+ prisoners), various forms of violence, enforced solitude, lack of privacy, lack of meaningful activity, isolation from social networks, insecurity about future prospects (work, relationships, etc.), and inadequate health services, especially mental health services, harm mental health. The prevalence of poor mental health and substance use among prisoners is considerably higher than in the community, and studies worldwide have shown that suicide rates in prisons are up to 10 times higher than those in the general population. Nevertheless, prisoners are also less likely to have their mental health needs recognized and to receive psychiatric help or treatment. They are most susceptible during the remand period. The ground reality is that even the largest prison in Karachi does not have a proper psychiatric team (comprising of psychiatrist, psychologist, social worker, occupational therapist and trained psychiatric nurse) in public capacity. Based on international data, the prevalence of mental disorder in prisons is over 40% if not closer to 60-70%.
While the directive to the IG for prisons to visit the prisons, and submit a report regarding the number of prisoners suffering from mental ailment in all the prisons in the province, including the women and juvenile jails, which are a highly vulnerable part of the community, is a laudable step, but the IG may not be able to perform this task alone and will need the expertise of specialists to gather reliable data upon which any action is to be based. Generally, it is expected that jail inmates should be given such an environment that make them useful members of the society upon release, instead of reinforcing serious behavioural issues. It is worth noting that the Psychiatry Department of Jinnah Postgraduate Medical Centre, Karachi is conducting research with Queen’s University in Canada to address this issue.
The court order stated that since `place of safety’ and `psychiatric facility`, as defined in the Act, was specific and meant for the special purpose, but the same purpose could not be achieved by the authority unless the details were available. Thus, the court’s direction to all the commissioners as well as the Director General and the Secretary Health to provide details of the facilities with regard to mental health, including the hospitals, centres, homes in the public or private sectors, for the mentally challenged persons is crucial to the improvement of mental health in the province.
They were also told to point out the buildings or lands, which were specified for the purpose but were occupied by any authority or private persons. It is important to note that PIMH (Punjab Institute of mental Health) recently faced a similar issue, as it was handed over to SIMS (Services Institute of Mental Sciences), instead of making it an autonomous institute, to improve and develop its services in all the areas of psychiatry. PPS has shown serious concern on this rearrangement, and has endeavoured and raised the issue with various policy-makers to take steps to restore the institution to its actual purpose at par with the international mental health institutions. This judicious directive of SHC would serve as a landmark throughout the country as provisio of health and mental health facility (with its specified purpose) is a fundamental right and the responsibility of the state. The SHC also called a report from the authority and the board, constituted under sections 3 and 4 of the Sindh Mental Health Act, 2013 with regard to holding meetings and starting initiatives for which they were established. It ordered the Chief Secretary to ensure the establishment of the mental health authority and board if the same had not been set up in terms of the provisions of the Act so far. Fortunately, Sindh has taken a lead in this regard, and established a presently functioning mental health authority despite its limited resources.
Besides, the Health Secretary was told to submit details of the strength of psychiatrists working in Sindh in the public sector. There is a dearth of mental health workers, including psychiatrists, psychologists, nurses, social workers, occupational therapists and other paid mental health workers, both in the province and in the country. Presently, Pakistan Psychiatric Society, the pioneer representative body of psychiatrists in our country has 445 (Sindh: 156, Punjab: 189, KPK: 52, Balochistan: 25, AJK: 7, and GB:1) registered psychiatrists to serve a population of more than 200 million. It is pertinent to note the majority of the psychiatrist are in the major cities of Pakistan and most of districts especially in the periphery are lacking qualified psychiatrist, for example: 18 districts of Sindh are devoid of psychiatrists and other mental health professionals in the public sector. There are only a few child psychiatrists and unfortunately, there are no qualified forensic psychiatrists in Pakistan. Presently, PPS is working on collaborating with NHS Scotland (The State Hospital/School of Forensic Mental Health) for training leading to approved psychiatrists, as per the requirements of the mental health laws. Moreover, PPS is planning a liaison with Forensic Psychiatrists of Pakistani-origin, working in Canada and Australia for the training of all the key-stakeholders related to law.
Furthermore, mental healthcare must be delivered at the community level. More non-specialists, such as Primary-care Physicians/General practitioners should be trained to deliver basic care to those who need it. Building on the strength of communities to provide mental health in the patient’s immediate environment would sustainably improve lives.
In the given circumstances, the directives of the Court to the various offices to communicate the order through all modes to the provincial authorities concerned are crucial; particularly it directed the SHC’s Member Inspection Team-II office to also communicate this order to all district and sessions judges.
Looking at the current situation of the country, it’s high time that we as a nation must prioritise mental health and invest in it as our national asset. This in turn will aid to alleviate poverty, enhance productivity, improve interpersonal relationships reducing conflicts and chaos, and create political and economic stability, giving our country a positive outlook leading to prosperity of our nation and the region.
Prof. Dr. Muhammad Iqbal Afridi
M.B.B.S., M.C.P.S. Psych (Pak), F.C.P.S. Psych (Pak), F.R.C.P (Ireland)
President, Pakistan Psychiatric Society
Dean, JPMC (Jinnah Postgraduate Medical Centre), Karachi, Pakistan
Dean, Faculty of Medicine, JSMU (Jinnah Sindh Medical University), Karachi.
Head, Dept. of Psychiatry & Behavioural Sciences, JPMC,
Member, Sindh Mental Health Authority