“Hum bazm-e-jahan ki raunaq hain” (We are the liveliness of the world) — Faiz Ahmed Faiz’s unpublished poem written for the first World Conference on Women, Mexico City 1975.
In the barrage of bad news about Pakistan, one little known fact is often overlooked. The people of Pakistan lead South Asia in charitable giving. Time and again, it has been proved that when it comes to good causes, Pakistanis will always rise to the occasion. This is as true in healthcare as in any other field. Our latest political hopeful, Mr Imran Khan will testify to the fact that his pioneering Shaukat Khanum Memorial Cancer Hospital and Research Centre thrives on the donations of well-intentioned Pakistanis both here and abroad.
However, there is one aspect of healthcare that is relatively neglected, not just in Pakistan but all over the world. Patients with mental or psychiatric illness often suffer the dual burden of not just their illness but society’s disapproval of it, starting with their own families and loved ones. Suffering no physical wounds or disfigurement from their illness, they are often subjected to ridicule and hostility and rejected as frauds and liars. All medical research contradicts these hard to combat prejudices. This stigma is a major barrier to expanding access to treatment for mental illness in spite of the fact that depression is one of the fastest growing illnesses in the world according to the World Health Organisation (WHO) statistics. It is predicted to overtake heart disease as a major cause of morbidity (disease burden) and mortality (premature death from disease) by 2020.
In addition, in this day and age when development is being targeted specifically towards women and children, it is often forgotten that the burden of mental illness, globally, falls disproportionately on women. Women suffer more from the commonest mental illnesses such as anxiety and depression although men make up an equal portion of the sufferers of other mental illnesses such as schizophrenia and substance abuse.
It is no secret that the women of Pakistan are especially unfortunate. As in most ‘third world’ countries, women, as one of the most disempowered sections of society along with children, bear the heaviest burden of all illness, including mental illness. It does not help that the occurrence of mental illness is closely tied to a woman’s reproductive cycle. Beginning with menarche (the onset of menstruation signalling sexual maturity), the normal, monthly hormonal fluctuations in a woman’s body predispose her to mood swings, sleep problems and an increased chance of depression and anxiety, especially during ‘that time of the month’. Most women feel irritable, anxious and may have mild sleep problems during this time but do not feel hampered in their day to day functioning. In some women, the symptoms can progress to overt clinical depression or anxiety or more severe illness that may require medical help.
The next stage of high risk of development of mental illness is pregnancy and the postpartum period. Again, some mood symptoms are common and normal but in some cases, depression, anxiety or more severe symptoms can develop and in the most severe cases can imperil the life of the mother and/or the baby. This is especially true in the immediate postpartum period (one to three months after delivery). The occurrence of such illness in one pregnancy increases its chances of reoccurring in subsequent pregnancies. This is complicated by the fact that up to 84 percent of women in Pakistan do not have access to elementary methods of birth control that would allow them to plan and space pregnancies for optimum health.
Pakistan is a dangerous place for mothers and infants. The Pakistan Demographic and Health Survey (PDHS) 2006-2007 shows an infant mortality rate of 78 deaths per 1,000 live births (94 per 1,000 live births before age five, i.e. almost one in 11 children dead before their fifth birthday). Pakistan’s maternal mortality rate is 276 per 100,000 live births and has remained virtually unchanged since 1991. By comparison, Bangladesh’s infant mortality rate is less than half that of Pakistan at 38 per 1,000 live births and its maternal mortality rate is 194 per 100,000 live births down from 322 in 2001!
In addition, Pakistan, also like other third world countries, is plagued by the demons of ignorance and superstition. In the rural areas it is common to find women with easily treatable mental health problems being sent to ‘Pirs/Faqirs’. There, they are ‘diagnosed’ as being possessed by ‘jinns’ and administered ‘treatments’ such as being beaten soundly with sticks, being made to inhale corrosive spices or being subjected to bloodletting by making cuts on their faces or scalps to allow the evil spirits to escape. In addition, these charlatans often rape and otherwise sexually abuse women (sometimes girls younger than 10) while charging their families exorbitant amounts of money to ‘cure’ them.
In the cities, there has been a mushrooming of ‘alternative medicine’ practitioners from the well-established (yoga, massage, acupuncture) to the exotic and totally unproven (‘gem therapy’) to the bizarre (‘bee therapy’). While traditional medical practice has its limitations, especially in chronic conditions, there is no justification for spending money on unproven and sometimes frankly dangerous ‘treatments’. Many of these conditions could be eradicated with better education and more widespread availability of well proven therapies.
The measure of a society’s well being is how it treats its most vulnerable citizens. By that measure, Pakistan is failing miserably. While we are plagued by the same problems that bedevil other developing countries (lack of resources, low literacy levels, poor infrastructure, a continuous ‘brain drain’ to richer countries, etc), our neighbours (Iran, India, Bangladesh, China) have made gigantic strides in the last couple of decades while we have been standing still or sliding backwards. If we are serious about not losing yet another generation to preventable illness, getting serious about mental health, especially women’s mental health, would be a good place to start.
The writer is a psychiatrist practicing in Lahore. He can be reached at [email protected]