A part from the human rights issues of the silent sufferers of mental illnesses, the physical shrinking space for mental health units and the lack of concern for mental health in Pakistan is now clear as day.
The worst has happened to the Mental Hospital, Lahore, which was renamed Pakistan Institute of Mental Health (PIMH); it has lately been engulfed by the Services Hospital (through a notification issued on January 7, 2019). The fate of Giddu Bander, the mental hospital in Hyderabad, renamed as Sir Cowasjee Institute of Psychiatry (CJIP), hangs in the balance after the Anti Narcotics Force (ANF) set up an addiction unit on its premises. The ruin of Dader Mental Hospital in Mansehra is now too old to recall and protest as it was shifted to the TB Sanatorium, with shrunken bed strength, to establish the Hazara University in its place.
After Partition in 1947, Pakistan inherited two mental hospitals, one with 1,400 beds at Lahore, built in 1840, and the other with 495 beds in Hyderabad, built in 1856. Meanwhile, the psychiatric ward in Peshawar prison expanded into a mental hospital. The 100-bed Government Mental Hospital at Dodhial, Mansehra, was the first mental hospital established after Partition, in the early 1960s.
Mental health facilities are suffering shrinkage of space while mental health sufferers remain voiceless
At present, the total number of psychiatric beds available in mental hospitals, state-run medical colleges and private psychiatric facilities is approximately 5,000-6,000, while there are only 500 psychiatrists, mostly practicing in major cities.
The Pakistan Medical and Dental Council’s (PMDC) criterion for recognition of a medical college was that psychiatry should be taught as a compulsory subject. A long and persistent advocacy by the Pakistan Psychiatric Society for teaching psychiatry at undergraduate medical colleges was met with partial success. Such departments of psychiatry were set up in medical colleges with a psychiatrist and 10-25 beds (mostly with no psychologist or psychiatric social workers). It is estimated that in the state-run medical colleges of Pakistan, there are approximately 700-800 beds.
A review of what is happening at the few existing mental hospitals situated at prime locations would clarify the low priority given to people with mental illness. While advocating that these patients should be treated as human beings and given the benefit of brain research and psychopharmacology, this write-up highlights the issue of prioritising prime land over human misery.
SIR COWASJEE INSTITUTE OF PSYCHIATRY, HYDERABAD
Sir Cowasjee Jehangir, a Parsi engineer, established a trust on an area of 32 acres of land for people with mental illnesses in 1856. The land is still entered as such in the Revenue Record of Rights. From Giddu Bander to Sir Cowasjee Institute of Psychiatry (CJIP), the facility has been under attack recently more so than in the past.
The CJIP received the first insult in 2004 when the residential quarters area, measuring 4,125 square yards inside the institute, was given away free of cost to the financially lucrative College of Physicians and Surgeons Pakistan (CPSP).
The Association for Mental Health raised its voice on behalf of the patients and even wrote a letter to the President of Pakistan (Dawn, March 15, 2005). Earlier, the former chief minister Sardar Ali Mohammad Mahar of Sindh had refused a similar request for 2,000 square yards of land in Karachi’s Civil Hospital. But then Sindh governor Dr Ishratul Ibad allotted and inaugurated the regional centre of CPSP. The allotment is illegal because the trust land cannot be used for any other purposes than what was intended.
An NGO, Basic Needs, was handed over a barrack for rehabilitation, though food and medicine are provided by the CJIP. The rehabilitation programme may be better organised but the unit has changed several hands and the illegality of the process needs correction. Another infringement is the allotment of a bungalow to an official of an entirely different department.
Now the Anti-Narcotic Force (ANF), Sindh, has taken over a newly constructed building inside the institute to establish an addiction unit and run it independently. This is an illegal step as the treatment and rehabilitation of drug addicts is the job of trained psychiatrists and psychologists; the ANF’s job is primarily to control production and smuggling of narcotics. In the 1970s the Narcotic Control Board’s attempt to treat and rehabilitate drug addicts had failed. It is widely known that such Anti-Narcotic Treatment and Rehabilitation Units soon become the centre of drug smuggling and sale. Inevitably, patients with mental illness in the institute will have narcotics available to them on the premises. The Additional Director of Health Department has made the MOU public through a letter dated December 4, 2018, released on January 16, 2019. The Pakistan Association for Mental Health has strongly protested against this high-handed encroachment. The ANF must surely have enough funds to establish such a facility, preferably away from mental hospitals.
PUNJAB INSTITUTE OF MENTAL HEALTH, LAHORE
The current state of the Lahore Mental Hospital, recently renamed Punjab Institute of Mental Health (PIMH), is a tragedy in itself.
The Services Hospital — now renamed Services Institute of Medical Sciences (SIMS) — and the Punjab Institute of Cardiology (PIC) were established on the land donated more than a couple of centuries ago by a Hindu family, Rani Ichree, for a mental hospital. Originally, it was claimed to be approximately 160 acres of land but illegal encroachments have shrunk the premises to 50 acres only.
With the connivance of the Medical Education Department, Punjab, through a notification dated January 7, 2019, PIMH has been merged lock, stock and barrel as a subordinate entity with SIMS. The administrative control given to the Sims is a complete loss of identity for the 1,400-bed facility.
The Anti Narcotic Force is also planning to set up a 100-bed addiction unit within the premises of PIMH.
THE DHODIAL MENTAL HOSPITAL, MANSEHRA
The Dhodial Mental Hospital, Mansehra, was established in 1960. It was named the Government Mental and General Hospital and accommodated 100 beds. It was run by its devoted director Dr Irfan for a long time. In 2001, the facility became a part of the TB Sanatorium to establish the Hazara University at Dhodial.
With the connivance of the Medical Education Department, Punjab, through a notification dated January 7, 2019, PIMH has been merged with Services Institute of Medical Sciences (SIMS).
Due to a lack of maintenance and the 2005 earthquake, the hospital structure was severely damaged. Without any efforts to make it safe, the services were run by non-qualified psychiatrists until recently.
BALOCHISTAN INSTITUTE OF PSYCHIATRY AND BEHAVIOURAL SCIENCES, QUETTA
Decades ago, a trainee from the Jinnah Postgraduate Medical Centre (JPMC) started a humble department of psychiatry at Bolan Medical College. More recently, Dr Ghulam Rasool succeeded to upgrade the department to Balochistan Institute of Psychiatry and Behavioural Sciences (BIPBS). It is hoped that it does not fall prey to a cosmetic change of name only. There is great hope as the institute has a panel of dedicated and qualified psychiatrists.
In early December 2018, the Chief Justice of the Supreme Court of Pakistan, Saqib Nisar (now retired), ordered the Punjab and Sindh health departments to constitute committees and submit reports within three weeks on the state of affairs of mental hospitals in their respective provinces with proposed improvements in their functioning.
The two committees were constituted with Prof Saad Bashir Malik (Punjab) and myself (Sindh) as conveners. The respective committees submitted their reports within the given time. The Sindh Committee sent their detailed report on December 31, 2018, and Prof Malik also submitted his report around the same time. The Chief Justice retired on January 18, 2019 and did not get time to review and order the implementation of the recommendations. The committees now hope the new chief justice will pursue and order in favour of people with mental illnesses. Psychiatrists and patients are already agitating against the recent encroachments by the two provinces.
While internationally the old prison-style mental asylums — later mental hospitals — are being closed down gradually with ambitious community mental health programms and for human rights reasons, no alternative has been envisaged in Pakistan.
According to a colleague, when Ghora Hospital can be converted into University of Veterinary and Animal Sciences (UVAS), why can’t mental hospitals be raised to be centres of excellence such as a University of Mental Health and Behavioural Sciences.
In view of the massive nationwide demolition of illegal shops and houses of poor daily wage earners, there is a strong case for demolishing the CPSP’s regional centre and not allowing illegal possession/transfer of land belonging to the voiceless suffering from mental illness.
The writer is president of Pakistan Association of Mental Health
Published in Dawn, EOS, February 17th, 2019