Prioritise mental health

How can you defend someone who is lying on a hospital bed waiting for his mother to feed him, wipe his mouth and then keep searching for a son she lost to a flawed justice system years ago? Or someone who hasn’t been able to speak for over a decade or someone who has lost all rational connections with his surroundings and now lives in a world of his own?

All these people have been on death row, despite having decades of documented history of mental illness – all of them waiting for the apex court to review its judgment that failed to recognise schizophrenia as a ‘permanent mental disorder’. Khizar Hayat, Kanizan Bibi and Imdad Ali were unable to comprehend the meaning and rationale behind the harsh sentences they had been given yet and all of them were served with dear warrants only to be stayed after court interventions.

Last year, the Supreme Court of Pakistan in its landmark judgment in the clubbed cases of mentally ill death-row prisoners reviewed the issue of mentally ill defendants at length for the first time. The court not only declared executing individuals unable to comprehend the meaning and rationale behind their sentence unjust, it also reiterated the existing safeguards for persons with mental disorders laid down in our legal framework. The court commuted the death sentences of Imdad Ali and Kanizan Bibi and stayed the execution of another mentally ill prisoner Ghulam Abbas and ordered the government to send a fresh mercy petition with all his medical records. Many lives have been saved and one can hope that no one with mental illness will be sent to the gallows now.

The judgment provides a roadmap to follow. Federal and provincial authorities were directed to immediately amend laws, establish forensic mental health facilities, constitute medical boards and launch training programmes for mental health practitioners, judges, prosecutors and lawyers. These directives are unprecedented and provide adequate guidelines to reform the criminal justice system. Lawyers and judges now have a precedent to follow, the executive has the task to establish medical boards and lawmakers have to introduce reforms. But do we have all the answers to our mental health crisis? Why were prisons the first mental health facility for these and hundreds of other prisoners? Why was their mental illness only diagnosed when they became an administrative problem for the prison officials?

Pakistan is on the verge of a severe mental health crisis, with a rise in patients suffering with psychotic symptoms, and an alarmingly inadequate mental healthcare structure. The surge must have been caused by the climate vulnerability, economic insecurity and the social disruption caused by the pandemic. We have 50 million who suffer from common mental health disorders and we only spend the 0.4 percent of our meagre health budget on mental health. This is a public health crisis and it requires a policy shift. A shift as monumental and unprecedented as the Supreme Court judgement.

A realisation that our mental health infrastructure is woefully underfunded, there are not enough mental health practitioners, and that there is crippling stigma attached with mental illness at the policy level can be the place to start. It can be argued that the enactment of provincial mental health legislation in all federating units shows that the public representatives are aware of the need, but unless these laws are matched with effective concrete measures we will remain vulnerable.

Since the 18th Amendment and the devolution of health services to provinces, Sindh has taken a lead by first enacting a mental health law in 2013 and then establishing a mental health authority. Sindh has also been the first and the only province to arrange mental health training for prison officials who are also the first responders in almost all of the mental health emergencies in prisons. These are commendable first steps but much more is to be done – much more that is not flashy, front page headline stuff.

Our political resolve often manifests itself in the form of humongous megaprojects with ribbon cuttings and flashy headlines, ignoring the fact that these systemic problems (and a lack of infrastructure in the case of mental health issues) require structural reforms. The mental health system cannot afford a political stunt; it needs a political consensus at every level.

First, all provinces have to constitute mental health authorities and introduce mental health services as a part of our primary health care system. Second, budgetary allocations have to be increased exponentially to set up mental healthcare facilities. Third, educational institutes providing specialised and subspecialised courses must be established in the public sector to fulfil the need of practitioners for an ever-increasing population. And, finally, people must be sensitised about mental health issues to destigmatise mental illness.

We need to dispel misconceptions associated with psycho-social disorders that are deep-rooted within our culture. These misapprehensions have forced countless to suffer without knowing that healing is possible. Many of us have unknowingly and wrongly been linking mental illness with violence, making it harder for us to separate the myth from the fact. Maybe the mentally ill rescued by the apex court weren’t only the victims of a flawed justice system, but also were let down by our negligence. Unfortunately, this will continue to happen unless we prioritise mental health.

The writer is a human rights

defender and political activist.

She tweets @MalaikaSRaza