There is a need to initiate a meaningful discussion on the need for mental health legislation in Pakistan, with special reference to the Sindh Mental Health Bill of 2012, currently being considered by the government of Sindh.
My main interest is with the mentally disordered patient, commonly referred to as ‘madman’, 'pagal', or ‘charya’. I have used these immensely distasteful and stigmatising colloquial expressions to emphasise the social ostracism and the desperate plight of this extremely vulnerable group of our compatriots. There is an urgent need to enact legislation for this group of citizens, who deserve both protection from others, and treatment for the mental disorder they suffer from, which renders them unable to seek medical treatment for themselves.
The horrendous status quo In the absence of meaningful mental health legislation in Pakistan, the current situation is that a person suffering from some mental disorder is almost completely at the mercy of his family, if they have one.
In the majority of cases, it is the family that brings these patients for treatment to the doctor, or whoever graces that professional role, i.e. the spiritualist, the holy man, the mulla or the quack. Where involuntary admission to a psychiatric institution is required, the patient is coerced first into admission and then psychiatric treatment, by the family as well as institutional staff.
There are currently no legal checks, protections or safeguards for the mentally disordered patient in any of these settings — at home, the errant husband can keep his mentally disordered wife locked up in the cellar for a long time, and in an institution, the doctor can allow his wealthy mentally disordered patient to remain admitted in hospital for as long as he wants. Where there isn’t a family, the mentally disordered patient is at the mercy of state institutions, primarily the criminal justice agencies — the police and the prisons. They are arrested, abused and, in some instances, killed as scapegoats. There has been a spate of recent cases where blasphemy offences are alleged against such mentally disordered patients, and the state institutions have failed to protect them from vigilante mobs imposing lethal instant retribution upon them.
Constitutional justification for mental health legislation The constitution of Pakistan guarantees basic rights and liberties to all citizens of the state. These rights derive from fundamental principles of justice in accordance with which the State of Pakistan assumes the sole monopoly of power over its citizens. But this arrangement, in order to remain just, assumes that the citizens have the necessary mental abilities to utilise their basic rights and liberties. In the presence of mental disorder, for example, such rights and liberties are hollow rights and liberties and mean nothing. As parens patriae, the parent of last resort, the state must ensure that its citizens receive treatment and protection in case they become mentally disordered. There is also an over-arching prima facie law of humanity which obliges us to show compassion to the ill among us, and to provide succour and treatment for them, in a manner which doesn’t do them harm. Mental health legislation is essentially an expression of this humanity which enriches our association with each other for the art of living.
History of mental health legislation and Pakistan Historically it was the reported abuse and neglect of mentally disordered patients in society which created the impetus and the political will for mental health legislation in the western world.
In the 18th century England, private madhouses had proliferated and there were a few notorious scandals reported where husbands had paid large amounts of money to unscrupulous, non-medical ‘madhouse’ keepers to detain their first wives, so that they could marry again. There were parliamentary enquires which revealed that this practice was not uncommon amongst Georgian gentlemen, and that along with illegally detaining non-mentally disordered patients in institutions for the mentally disordered, the care for those who were in fact mentally disordered was also scandalously poor. In both the cases the madhouse keepers were simply interested in making financial gain from the practice, rather than delivering any form of care and treatment for those they detained in their facilities.
There arose an urgent political and social need to introduce legal protections and the first mental health legislation, the Madhouse Act of 1774 was passed, both to ensure that those who were not mentally disordered were not subjected to abuse of any kind, and also to provide some safeguards for those found to be suffering from mental disorders and in need of involuntary admission and treatment.
Pakistan inherited the Lunacy Act of 1912 which was largely ceremonial in its impact upon psychiatric care in the country. There was little progress on this front until 2001 when the first Pakistan Mental Health Act of 2001 was passed.
There was again very slow progress, and it took many years for the federal government to set up the federal structural framework which would allow this Act to work.
However, after the 18th constitutional amendment was passed in April 2010, the provision of psychiatric healthcare was devolved from the federation to the provinces in Pakistan. This constitutional amendment in effect abrogated the 2001 Mental Health Act which had been premised on federal (and not provincial) psychiatric regulatory institutions. At present, in practice there is no law which protects mentally disordered patients in Pakistan.