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Prisoners or patients?

April 28, 2018

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A YEAR ago, this paper reported the suicide of a 45-year-old undertrial prisoner in his cell at Adiala Jail. The prisoner had been charged with his wife’s murder, and was known to suffer from mental illness for two years. Because mental illnesses are nearly always treatable, suicides, especially those that happen in jail, are preventable. His incarceration in an ostensibly secure environment should have afforded him access to basic rights including medical treatment. Like so many others with mental illness, our prison system failed him.

According to rough estimates, Pakistan is home to about 100 prisons including central jails, districts jails, sub-jails and special jails. While the existing prison capacity is less than 50,000, occupancy often exceeds 80,000. Two-thirds of the occupants are in remand (awaiting trial). Our ‘prisons problem’ is compounded by the fact that our jails are understaffed and under-resourced, which in turn perpetuates inefficiency and corruption.

Custodial torture is another serious rights violation that plagues Pakistan’s prisons: in 2015, four prisoners died from prison torture, while one was beaten to death by other inmates. These are just the reported figures. The Human Rights Commission of Pakistan regularly highlights the sad state of Pakistan’s prisons, including the problem of overcrowding: “In some prison barracks, a few prisoners had to stand while the others slept … prisoners could not access the washroom in the night because sleeping prisoners covered the entire barrack floor”.

The World Health Organisation and the International Red Cross identified the following factors that have an adverse impact on prisoner mental health: overcrowding; violence; enforced solitude; lack of privacy; lack of meaningful activity; isolation from social networks; and inadequate mental health services. It should come as no surprise that our prison system scores poorly on all these.

Our jail system is designed to punish without recognising the mental health needs of inmates.

Psychiatric morbidity and the risk of suicide increase exponentially in prisons. In the UK, nine out of 10 prisoners suffer from a mental or substance use disorder. Although the exact prevalence of mental disorders in Pakistani prisons is unknown, the figures are likely to be close to global estimates. Last year, the inspector general of prisons in Punjab submitted a court report certifying 57 prisoners as mentally ill; but only 27 of them had seen the inside of a hospital.

According to a report by the United Nations Office on Drugs and Crime, nearly 800 female prisoners in Pakistan’s jails face harassment, insanitary conditions and lack of proper healthcare. Female prisoners routinely experience sexual harassment and abuse at the hands of jail wardens, and concurrently report depression, sleep problems and suicidal tendencies.

Findings from another study show that in Peshawar’s Central Prison, the incidence of depression in women was 60 per cent. It is also common knowledge that there is an overwhelming representation of people with learning disabilities in our prison system. One study carried out at Central Jail, Faisalabad, revealed that over 60pc of prisoners had access to drugs, and that prison staff was responsible for supplying contraband.

At the moment, Pakistan does not have forensic psychiatry services — a specialised branch of psychiatry that provides assessment and treatment of offenders with mental illness in prisons, secure hospitals and the community. Such psychiatric expertise is routinely required to assist criminal justice proceedings to certify cases presenting with an insanity defence (those pleading insanity at the time of the offence) or the fitness of a prisoner to stand trial or undergo a sentence. Of late, a few high-profile cases have highlighted the need for psychiatrists as expert witnesses, as well as for concerted efforts that can plug the gaps in forensic mental healthcare.

For now, only traces of forensic services are seen as the local psychiatrists provide rudimentary clinical care at the district level and some tertiary care centres provide arbitrary medical reports for a limited number of undertrial cases when requested by the courts. This state of affairs exists despite the Mental Health Ordinance of 2001 and subsequent provincial legislation in Sindh, Punjab and Khyber Pakthun­khwa, clearly underscoring the need to protect the rights of offenders with disabilities and/or mental illness and to establish forensic psychiatric services.

Unfortunately, our prisons system is singularly designed to punish, deter and incapacitate, without duly recognising the mental health and psychological support needs of inmates. It is essential to understand that people are sent to prison as punishment, not for punishment, and that humane treatment should be indispensable in any prison environment. A 1997 report by the Law and Justice Commission of Pakistan described the objectives of Pakistan’s prisons as: custody, care, control, correction, cure and community. Essentially, mental healthcare has overwhelming scope in accomplishing these 6Cs. Not just that it is an integral aspect of basic healthcare, but it also helps keep prison environments disciplined and safe. Further, supporting and motivating prisoners is vital for their rehabilitation to become useful members of their communities.

To play their role effectively, the district psychiatrists require extensive training and advanced understanding of the interface between mental health and the law. And more must be done in terms of postgraduate training in psychiatry too: at present, trainees are only exposed to a basic understanding of the legal complexities of the prison system. Given the dearth of specialist services, doctors and key staff working closely with prisoners must be trained in mental health awareness, and in recognising common mental disorders. Prisoners should be screened for mental health problems on entry into the prison system and at least once a year afterwards. Effective policies to address overcrowding, abuse and violence, and promote vocational rehabilitation can help check the prevalence of mental disorders among inmates.

The mental health needs of vulnerable groups of prisoners such as women, older prisoners, children and young people, and prisoners from minority communities must be identified and accordingly addressed. Prisoners diagnosed with mental illness must be granted access to treatment and follow-up facilities. Separate accommodation is necessary for those with severe mental disorders. Effective referral pathways should be established for cases requiring specialist treatment in psychiatric units.

Ultimately, prisoners qualify as a vulnerable population; their mental healthcare needs should thus be seen as a social and ethical responsibility.

The writer is a consultant psychiatrist.

Twitter: @Asma Humayun

Published in Dawn, April 28th, 2018