What is the right thing to do?

This perplexing question has vexed many individuals since time innumerable. The moral reasoning is context specific. It can be based on individual’s frame of reference. “Love thy neighbor as you love thyself”, so argues the divine commandment. The injunction, for believers, might be the general outline; however, the individual meaning rests on their interpretation. The guideline for the unbelievers could be very simple though. The right thing for me might be quite different from the right thing for my neighbor. The problem with the conventional ‘right things’ are that they sound very impractical in this day and age. The commandment that ‘sin no more’ might be difficult first step in the current world of impulsive indulgence. The description of sin has also varied. While the sins of flesh have remained the same, the sins of the soul have become denser. The idea of not following the soul’s leading is alien in current times; leave alone the ability to decipher its call. The journey of (material) potentiality to (spiritual) actuality gives birth to the soul, which guides us to do the right thing. The matter, lacking intelligence could go awry. The metaphysical elements though so guide the intangible that the part actualizes the whole (The Holy one). The material life, so works against the individual will that it serves to impede it – cause it to strive more and more. Welcome the troubles, for they cause you to actualize your potential. The slaughter house of ‘success’ is for those who are deluded with life. What is failure? A flip side of success – a paradox of striving. What if, my soul has stopped telling me, what to do? His angels could have come down from the firmament in order to remind me of what I have forgotten. But there are no compulsions in the way of doing the right thing. I have to go back to the dyadic track, which I conveniently ignored. This could have been ages ago. The soul is immaterial. Divine will is eternal. The right thing is to listen to the soul, even if it tells you to do the things that you least desire. How do you differentiate the voice of the soul from some other (carnal) calling? There are no complex prescriptions in this regard. The voice of the soul is as natural as a cool breeze in the afternoon, or a rainfall in the tropical forest, depending on the context of individual person. However the desire to do the right thing, whatever it takes has to be a passion. An obsession, which dictates a constant, moment to moment, self renewal, until there is no space between the self and the (personal) truth. The individual so embodies the truth that his will become the God’s will and vice versa. An individual god is embodied in this way. Everything you do then becomes the right thing. The right thing could be attaining the enlightenment, the knowledge and the wisdom. As mentioned in the Holy Bible – Seek first the kingdom of God and his righteousness and all else shall be added up to you.

Social dimension of Psychosis

A general disclaimer: this article provides no succinct answers to the issues at hand. It is simply the discourse of a mind struggling to grasp the reality of a problem from the perspective of science and faith. Let me begin by declaring that these discordant entities need to move closer together, not just for the sake of an argument, but for a better quality of life for all those who seek answers.

Strangely enough, it’s a mystery why psychosis afflicts such a small percentage of the population — just around one per cent — considering all the minute things that could go awry in a structure as complex and fragile as the human brain. The incidence of psychosis and its unpredictable epidemiological distribution calls the attention of those who research at the cross border of mental health, anthropology and sociology. It has emerged that there are resiliency factors that operate to prevent psychosis, discounting the prevalence estimates.

However, the small proportion of those affected teaches us all we need to know about psychosis. The most obvious manifestation is the voices a patient starts to hear in his head, ‘ordering’ him/her to do things. Note that these voices always convey negativity — it is extremely rare to have ‘pleasant’ psychotic experiences! Mental health researchers have always placed great importance on the contribution of ‘expressed emotion’ in making a prognosis of psychosis. It has been established that there is a very close link between psychotic patients and overly critical and oppressive families.

So how do such seemingly trivial events lead to such a grave disorder? Many seem to expect a very complicated explanation — a solution to the mystery that could unlock the complexities of the syndrome. Yet there are no detailed explanations, only plain facts that stare us in the face. Does this give us another dimension of our existence to explore? Well, sort of. Our five senses aren’t alone in dictating our perception. Perception is a complex phenomenon, coordinated by the human mind. Besides the signals coming in from the sense organs, there are also avenues of insight which open within the mind — this is what we may call our subconscious or perhaps even ‘guardian angels’. It is difficult to scientifically define this phenomenon. This is the world of the unseen reality, which our minds experience every day. It is only when there is breakdown of barriers within the mind that unusual experiences are triggered. The internal struggle remains unabated. This struggle, witnessed by many of the remaining 99 per cent of the population is the social dimension of psychosis.

A review of literature shows that the idea of a mental illness being a manifestation of some sort of supernatural power has been around for centuries. For instance, Plato’s “Dialogues” portrays the esteemed Greek philosopher Socrates (470-399 BC) as a teacher and a man of reason who followed a divine voice in his head. Carl Jung (1875-1961), a Swiss psychiatrist and influential thinker, also greatly stressed the importance of understanding the psyche via religion, dreams, visions, etc. — in short, any form of “inspiration”. He was famous for recording all such “guidance” he received in the form of notes as well as paintings and even sculptures!

Such phenomena are so common in the annals of history and in literature that they can hardly be ignored, and may archaically be described as angels, or demons. The idea is not to argue about the existence of angels, but to describe, delineate and study the subconscious working of the human mind. Angels may have an existence seemingly invisible to our senses, but it is very real to an observant mind and a believing soul. Belief in their existence is testimony to the reality of truth that exists beyond our conscious perception. Disbelief leads to a state that ignores small fragments of the truth that could very well be assembled into the bigger picture.

True inquiry begins with accepting the limitations of one’s information and methods needed to acquire such knowledge. Let us conclude by stating that we don’t have enough information regarding the inner working of the mind, beyond a mere description of how various areas of the brain communicate through neural pathways and neurotransmitters, to really explain psychosis. The understanding of the neuro-centres where integration of information actually takes place is beyond the reach of the scientific methods available to researchers. We are in need of more robust technology, research paradigms and understanding which could explain the prevalent predicament in science

Shank’s mare

Missing a bus could be a wonderful experience, provided you utilize this time to ponder over your life’s curve. These small pockets of time could come handy if one is given to introspection. Other day, I missed a bus and I decided to tred back home by shank’s mare.

On the way back, I saw a swan sitting in the middle of the road, by the lake side, calm and cozy with her beak buried deep in her feathers. Instantly my mind went to the good Lord in the blue canopy above and around us, to whom we all belong, who is watching over us all the time. One’s heart and soul find peace and comfort in His reassuring presence. There are the situations when you could feel that God is around, in cool breeze ruffling the feathers of the swan, moments like these bring you closer to Him. We have to believe in His presence, only then we can actualize such moments. In the words of Lawrence, ‘if in this life we would know the serene peace of Paradise, we must school ourselves in familiar, humble, and loving converse with God”.

Some would argue that belongingness is a basic need for all human beings. It is a basic need like eating and sleeping, which we all need to have before we can move on to higher order needs on Maslow’s hierarchy. Fulfillment of this would encourage the search for higher order attainments – self actualization can only come once this is formidably consolidated.

One way to find real peace of mind is to follow one’s dreams and work towards actualizing the cherished goals in life. Any time management technique which doesn’t put a person in touch with his inner self is a marketing gimmick. Question to ask is why have we cramped our lives and time with clutter of activities – from absolute nonsense to things that we actually don’t enjoy doing? Happiness, we are told lies in pursuing worthy goals and actualizing our true potential. However before we can have it, we have to confront our fears of saying ‘no’. Only then we can redirect the course of our lives- individually and collectively. It takes courage to say no to an old routine, which has become a familiar way of life. The hound of disapproval might come back to haunt us. However saying yes to our dreams brings a new stride in our feet, an attitude with which we can actualize every possibility. With such small decisions we could redirect the course of our lives.

So on next working day, miss a bus or take a walk back home. Think about the course of your life. What needs to be shed – like an old cloth? This will make room for more challenges and happiness. You might also see a spectacle of joy and presence, telling you that you were created to be happy, to enjoy the serenity of days in your life. An everlasting presence might dawn upon you, fulfilling you days with peace and joy.

PSYCHEDELICS

Psychotropic drugs have the potential to induce psychedelic experiences, especially in vulnerable individuals. Their indiscriminate prescription by physicians – generalists and specialist alike – is a source of concern. It is chilling to know that pharmaceutical industry spends billion of rupees on their sales and marketing. The actual process of developing a molecule requires huge sum of money, which have its dividends in terms of financial profit. Though there is a need to keep the wheel of research and inquiry moving, the forces which drive the marked needs to be curtailed.
According to one estimate the psychotropic drug sale in Pakistan for a duration of one year (June 2003-4) were worth 2.76 billion; of these tranquilizers and hypnotics were 1.36 billion with a rising trend of 18% and 137% respectively from previous year. Situation is not any different in a developed country like United Kingdom. Department of Health data, UK, reports that General Practitioners in England wrote 12.7 million prescriptions at a cost of £20.9 million in 2002, compared to 15.8 million prescriptions worth £13.8 million in 1992. 30% of prescriptions were for 56 or more tablets. Due to rising concerns, the regulatory authorities in U.K have mandated that general practitioners will not prescribe Benzodiazepine – a tranquilizer – for more than two weeks. Those requiring a longer prescription should be referred to mental health facility.
The biggest barrier in Pakistan is the breakdown of regulatory forces. There exists a fine balance between, what is right and wrong. Physicians often cross that barriers, in a matter of convenience, often unthinkingly about the consequences of such transgression. The relationship between doctors and pharmaceutical industry is one such example. The drug companies spend millions of dollars, flying physicians to all part of the world, making trips to exotic locations in the guise of science. It is no more than a buying-off. There is robust evidence to suggest that they feed biased information to the practicing clinicians. The research, supported by drug industry, lacks soundness in terms of methodological rigor. They investigate and seek out those, who are going to have voice in their field. This is done purely for selfish reasons – to increase sales.
The rising trend of inflation, uncertain political environment and mayhem has forced marginalized individuals towards mental illness. In the scenario when there is a dearth of mental health professionals – a dismal number of 360 psychiatrists for a population 160 million- masses have no venue of help seeking. In the current situation, general practitioners are the obvious port of call. These physicians, lacking skills in recognition and management of mental disorders, prescribe psychotropic medications indiscriminately.
In a survey exploring the opinion of 360 general physicians from a representative sample of Karachi city, almost 50% reported that they would use Benzodiazepines in treating depression. Though standard antidepressants are safe and effective, only 31% suggested that they would use them in treating depression. More concerning was the fact that almost 63% general physicians were not aware of standard diagnostic criteria for depressive disorder. In this scenarios depression, the most common psychiatric syndrome, remains under recognized and in appropriately managed. The community based estimates of depression has been reported to be around 30%. This means that every third person is expected to be suffering from depression and anxiety. This is a huge burden of morbidity, which has a consequence on the psychosocial functioning of the country. The demand for services, redressing the mental health needs of the community is dire.
The sales of inject able narcotic analgesics in the drug-brothels has reached an alarming proportion. The epidemic of psychotropic’s and psychedelics needs to be curtailed. Over the counter availability of psychotropics adds to the menace of drug problem. Islamabad, on account of being miles away from the real Pakistan is oblivious to this reality. Since this has become a public health concern, the officials in the ministry of health, Government of Pakistan needs to take note of it.
This is a problem which cannot be handled by physicians alone. The prevalent mentality of patients, pill for every ill has to change. Civil society, government, media, teachers and religious scholars have to play their part.

Suicide Prevention day!

It is estimated that one million people commit suicide every year; one death after every two minutes. Rates of suicide vary over the course of life span. Among all the suicide related death 60% are happen in Asia. Concerning fact is that it is the highest cause of mortality in the age group of less than 30 years. Another grave statistics is the high estimates in married females. Suicide leaves a grave scar on the psyche of the family, which struggle with the remorse of this tragic event for all the days to come. While the relative may be alive physically, they lose the will to live. Most of them end up with depression. All efforts should be made in order to prevent this dreaded cause of death. Looking at its consequences, one death is too many, in case of suicide.
Suicide is on the rise in Pakistan, so informs research carried out over the course of decade at Aga Khan University. The various social and religious factors which use to protect people from the suicide are changing. The fine balance between the will to live and impulse to harm oneself is being disturbed. What are the factors which cause this: literature informs us that there are some immediate factors while other are long term contextual difficulties which makes people vulnerable to deliberate self harm. Social and economic deprivation makes people vulnerable to self harming behavior. World Health Organization (WHO) estimates that for every suicide there are at least 10 to 20 cases of deliberate self harm. Delayed dispensation of justice, social inequity, economic deprivation and sustained stress push people towards hopelessness. In desperation individuals resort to self harm. Once they cross this threshold than it becomes difficult to get back to the baseline mental health.
It is encouraging that there is an international recognition on the burden of this issue. A concerted effort on parts of International Association of Suicide Prevention (IASP) and WHO has made it possible to organize a World Suicide Prevention day on September 10th , 2009. This was organized initially in 2003, catching momentum in subsequent years. This year a conference is being organized at Aga Khan University on September 30th, 2009, with a theme ‘Suicide – Hidden realities in Pakistan.
This task is too important to be dealt by mental health care professionals, alone. Media along with the civil society has to play its role in propagating the message that suicide is preventable. This needs to be done in cultural context. One of the biggest impediments in reducing the stigma attached with this mental health problem is its legal status in the context of Pakistan. According to Pakistani law, suicide is a crime, punishable by jail term and financial penalty. Though conviction rates are low, it impairs help-seeking, limiting it to handful of centers with medico-legal cell. Most victims seek care in the emergency care departments of general hospitals, which are ill equipped, in terms of training and expertise related to psychological management of such cases. This slipshod approach leaves many hanging. Easy, over the counter accessibility of drugs is another menace which feeds this problem. Perhaps the most troublesome predicament is the availability of Organophosphates in the rural and semi-urban settings. It is not surprising that these factors contribute to the rising suicide rates.
Relatives and family members have to deal with the issues of Suicide. It is ironic when they get blamed for the death of the relative. However burden of this grief can be heavy; mind goes back to things which could have been done differently, the micro-expression of relief which, in hindsight, are dreaded way of saying a farewell to long period of misery. Therefore it is equally important to address the grief and guilt inculcated in the relatives of the deceased. Media when employed constructively can reduce the burden of this mental, social and public health problem.

Problem of Problems!

Once you have read everything in a Magazine then you come to a realization of ‘what’ to read, similar to the fact that once you have lived your life then you comes to a realization of ‘how’ to live. Having done so, one comes to a point where one feels like reaching out to people. This afterthought is an insight of varied paths which lie in front of us all; a canvas of possibilities on which we could paint varied pictures – a reality – emanating from our subjective consciousness. Taking this journey of introspection, one reaches the shores of internal realms where words and images blend in to eternal ‘Cause’.
Wise among us have taken that journey in order to discover the essence of all things. It is reassuring to know that where our efforts end, an everlasting will extend, in order to perpetuate our just cause. It is, as if, divine cause works to have our cause fulfilled. It is to give us mortar to create an eternal abode. Time loses its relativity and meaning in this journey of introspection, where there are no cycles of sun and moon, therefore, the rules are ever constant. However in this realm, observer as much influences the environment as much environment influences the observer. However, these influences are discreet. A desire will bring home what is cherished, moments become easy, creativity enhanced – one can bring in to existence his reality – based on past and current influence. However material world works against persons will – slowing it, denying it, asking him to strive more and more until he actualizes himself. Thus these, so called problems, shape his spirit and soul.
Those in the domain of counseling would attest to the fact that most of our problems are self manufactured. In general, the way we habitually think and feel about issues determine the way we approach a problem. The dark remorse and chains of regrets contribute too much heartache; it does not serve any one anything. It is best to close the doors on problems of the past and move on with the purpose of living. In fact, the very label ‘problem’ leads to dejection and disappointment. Relabeling them as an ‘opportunity’ or ‘challenge’ would impel us to muster all of the power towards a stimulus. It is like a laser beam (of concentrated effort) which can cut through thickest of steel-sheet. It is our choice to be like steel which is forged by a hammering of life’s problems or be like a glass which is shattered by a single blow. The determining factor in individual’s life is how he/she handles problems.
Then, there are circumstances which are beyond the control of mortals and which can very well be regarded as a problem. The death of a parent, wife, brother or any other significant other which seemed nothing but alienation, somewhat assumes the aspect of a guide. This may bring in a revolution in our way of life, terminating a period of dependency waiting to be closed. This may brings in a new era of growth, or formation of new acquaintances and reception of new influences which would herald in a new era of development. In the words of Ralph Waldo Emerson ‘ the man or women who would have remained a sunny garden flower, with no room for its roots and too much sunshine for its head, by the falling of the walls and the neglect of the gardener, is made the banyan of the forest, yielding shade and fruit to wide neighborhoods of men’.
Problems are growth-stimulators. It is through problems that human spirit is forged in to greatness, of one sort or another. Those without problems are relegated to deep waters of failure. In embracing the problems, one realizes the true meaning and zest of life; this entails growth and self actualization through deep study, earnest and sustained effort towards a cherished goal in life. However this only happens when one realizes the necessity of problems in one’s life, thereby encouraging a constant stream of difficulties. One would argue that this would lead to masochism of sort. Answer is: Highly unlikely. In fact this would ensure a steady growth and maturity.
In conclusion within every problem there are seeds of equal, if not more, benefits. Realization of these facts makes us cognizant of the necessity of problems. We welcome them for what new message they bring for us. Take out a paper and draw a line in the middle. Write problem on one side and opportunity on the other; subsequently make a sustained effort in converting these so-called problem in to an opportunities. Keeps this paper with yourself, for you will be astonished in few years time, how things have turned out!

Terrorism, Health and Responsibility of Intellectuals?

In contemporary times, the loss of skilled staff to incidences of terrorism is a matter of concern. The prime example of this tragedy is death of Surgeon General, Pakistan, Gen Mukhtar Ahmed Baig, in an incidence involving Suicide Bombing1. Suicide bombing is a strategy in which perpetrator intends to inflict harm on his victim with no exit strategy in mind. No place is immune to such incidences; acts of terrorism and suicide bombing have been carried out in Hospitals, private clinics and places of worships. The incidence of such gastly acts has increased since induction of Pakistan as a front line state in the War on Terror. One would argue this is a heavy price to pay. In this write-up we will examine the health related variables of terrorism.

Pakistan has seen a steady rise in the incidence of suicide bombing. Although accurate statistics are not available but according to one estimate 927 people have been killed in the acts of terrorism involving 71 suicide attacks in 2007, alone2. Subsequent years have seen a rapid rise in the incidence of Suicide bombings. Though there may be no virtue in counting the dead, lessons can be learned in order to rectify the mistakes. There are various determinants of this rising extremism in the country. A discussion on the political reasons is beyond the scope of this write-up; however, some would be sighted as a background to our main discussion.

Pakistan is a country with an Agrarian economy. The health related indices read a sorry picture; the neonatal mortality of 57 per 1000 live births and infant mortality rate (under one) of 78 per 1000 live births is a source of persistent concern3. We are beleaguered by a double burden of Infectious and Non-communicable diseases. There are those who are inflicted with cardiovascular diseases, obesity – much like western countries – due to affluence while the rest suffer from poverty, malnutrition and scarcity of clean water supply. In terms of economic resources we are classified as a Low- Middle Income Country while health related variables may be at par with Sub-Saharan Low Income Countries4. Community based studies site Prevalence estimates of common mental disorders (Depression and Anxiety) to be around 30%, which is double the figures from the industrialized western countries5. Conflicts and wars lead to migration of population, foremost to erosion of protective factors for mental health. Post Traumatic Stress Disorder (PTSD) is a common disorder under these conditions. Though there are no representative figures, of 1020 Afghan refugees presenting to a psychiatric clinic in Peshawar, North West Frontier Province, Pakistan, 76.1% (n=776) met DSM-III-R diagnostic criteria of PTSD6.

In a periodical, scientific American, Susser et al. writes ‘Terror does not always come out of the barrel of a gun or in the shape of a bomb or grenade. Intimidation, harassment, threat of violence or the creation of an environment of imminent violence can be enough to paralyzed civil life and kill enterprise and creativity. Such tactics can also lead to violent retaliation by those oppressed.’7 Lack of education and poverty are a breeding ground for extremist ideologies, duly funded by external Agencies and Governments. Armed conflicts lead to alienation of marginalized communities. In Pakistan, Study of Sociology and Anthropology are relegated to those with no options. In this context the policy-decisions are not informed with Research evidence.

Suicide bombing is not an outcome of religious extremism alone. It has various social, psychological and various geo-political determinants. Lack of development and economic opportunities are a breeding ground for extremist ideologies. Fighting terrorism with force is an exercise in futility. Suicide bombing is a symptom of a disorder. There is a dire need to treat the cause rather than control the symptoms, alone. The rise in religious extremism has affected health related initiatives in many ways. In immunization program, the refusals of polio vaccines have been a recent source of concern. Self-styled clerics in North West Frontier Province of Pakistan have claimed that the vaccines have been donated by ‘Western’ countries, with the aim to affect the ‘Faith’ of their future generation. It is of prime importance that Government initiates a dialogue with these religious leaders in order to find an impasse8.

Another important, yet neglected issue which is fallout of War on terror is Drug Use disorders. Heroin as a drug of abuse was virtually unknown in Pakistan prior to 1979. With Heroin addiction reaching epidemic proportion, over the past 40 years, Pakistan has become embroiled in a growing, complex and multi faceted narcotic menace. This has affected nearly all socio-economic groups. According to the 5th and last National Survey on Drug Abuse (N.S.D.A.) conducted in 1993 by the Pakistan Narcotic Control Board, there were nearly 3 million drug addicts in Pakistan with 51% of them being heroin addicts9. United Nation’s Anti-narcotics chief warned that Afghanistan burgeoning opium production was leading to the emergence of new “Golden Triangle” of lawlessness on the country’s borders with Pakistan, Iran and Turkmenistan. “Illegality is very pervasive and trafficking (is) going on,” said Antonio Maria Costa, executive director of the UN’s Office on Drugs and Crime. Recent reports show that Afghanistan saw a record harvest of 8,200 metric tons of opium in 2007, a 34% increase over 2006. The export value of the country’s opium is estimated at $4 billion (Euro 2.73 billion), up 29% on last year and equal to more than half of Afghanistan’s legal gross domestic product. The mountain terrain in the North Western Frontier Province of Pakistan has provided trade route to goods across the Afghanistan and central Asia for centuries. This has resulted in rising sale of hard drugs in Pakistan10.

Suicide bombing and terrorist activities are particularly more devastating in the context of restricted Medical resources of a Pakistan – a developing country11. Unfortunately, an organized Emergency Medical Services does not exist in Pakistan. The initial help to such trauma victims is usually provided by people at the scene of the terrorist activity, which mostly is nothing more than sending the victims to the nearby hospital in whatever form of available transportation. Transportation of these victims to the hospitals is also delayed by the traffic congestion; though the situation has improved in major cities due to the combined efforts of government and NGOs. In-hospital care for suicide bombing victims is also not very effective. The doctors and paramedical staff in the emergency department across the country, even in tertiary care hospitals, are not well trained for the care of suicide bombing victims. The situation of medical services is even worse in tribal areas of Pakistan, which have been badly hit by such incidents lately.

The gravest issue with terrorism is that it impedes development in all facets of life. Health care sector in no exception to this problem; damage to infrastructure, loss of skilled work-force, accessibility to centers and teaching and training opportunities are compromised. Terrorism affects the mental health of the masses direct as well indirectly. The stress of uncertainty leads to state of compromised functioning among those who are vulnerable.

In a larger frame of reference, the lack of development – in terms of human capital – is the biggest loss inflicted by terrorism. In the twenty first century, when stem cell research has opened the avenues for unveiling scientific mysteries, we cannot afford relegation to deep waters of ignorance. We need to initiate dialogue on issues confronting the masses. Universities should play their part in bringing together all stakeholders. Leadership in Academia should step out of their traditional roles and confront the bigger issues, courageously. Noam Chomsky, the famous American Cognitive scientist, linguist and Philosopher in his famed essay, ‘The Responsibility of the Intellectuals’, commented on the prevailing situation after the Second World War: ‘Let me finally return to Dwight Macdonald and the responsibility of intellectuals. Macdonald quotes an interview with a death-camp paymaster who burst into tears when told that the Russians would hang him. “Why should they? What have I done?” he asked. Macdonald concludes: “Only those who are willing to resist authority themselves when it conflicts too intolerably with their personal moral code, only they have the right to condemn the death-camp paymaster.” The question, “What have I done?” is one that we may well ask ourselves, as we read each day of fresh atrocities in Vietnam—as we create, or mouth, or tolerate the deceptions that will be used to justify the next defense of freedom’.11 The same question confronts many intellectuals in this country beleaguered by war and terrorism.

Pathways to Care: Experience from Pakistan

In order to recover from disease and improve health, patients choose different forms of treatment and care. A delay at any stage could be detrimental, leading to psychological, social or medical complications.

Research form the West has shown that general practitioners (GP) are the gatekeepers to specialised psychiatric services. This is similar to a model constructed by Goldberg and Huxley, proposing that patients have to pass through three filters in order to reach specialised mental health care (community-GP-psychiatric care).

In Pakistan, there are three main mental health service providers: the specialists in private sector, the government and traditional healers. Most of the government run mental health facilities are urban, mismanaged, poorly resourced and understaffed with irregular provision of medications. Generally, the poorest sections of the society visit these hospitals since they have no other options available. The rest prefer treatment from private medical specialists.

But even that has its own problems. It is unregulated while monetary exploitation and abuse of patients is not uncommon. This is particularly so in patients with schizophrenia, which leads to delay, thereby increasing the psychosocial morbidity and burden of illness. This is further compounded by the extreme dearth of psychiatrists and other mental health professionals in the country. For example, it is estimated that there are only 360 psychiatrists for a population of 160 million.

According to the World Health Organization (WHO), mental healthcare services should be integrated with general health services and provided in a decentralised manner. It is also beleived that trained health professionals are scarce in developing countries. If proper health care is to be brought within reach of the masses, primary healthcare physicians must work in collaboration with specialised personnel.

Research from the West and developing countries shows that about a quarter to half of the patients in primary care have mental health needs that have not been addressed. Due to poor awareness and resources, primary care staff has not been trained to treat and manage mental illness, thereby fulfilling the need-supply gap. This model was conceived by psychiatrists in the western countries with administrative convenience and well-established primary healthcare system.

In Pakistan, primary health is poorly developed with weak referral chain from primary to secondary to tertiary care services. Most patients by-pass the primary care services and access services at secondary and tertiary care centres directly. The main reason is the poor quality of services offered. Additionally, in the absence of any kind of health insurance, most patients pay out of their own pockets.

Studies on integration of mental health services in primary care centres in Pakistan are inconclusive. The issues involved are related to the perception of government-run primary health care services as well as the costs involved, knowledge of services, stigma, pathways to care and design issues.

A few years ago WHO and Pakistan medical and research council (PMRC) did a survey in order to study the reasons behind the poor utilisation of available BHU services. Low numbers and attendance rate of doctors (63.8 per cent), non-availability of medicines (22 per cent), geographic inaccessibility and low quality of services were some of the major factors. Public sector tertiary care hospitals (TCH) are a major recipient of government budgetary allocation, leaving little resources for improvement in the available primary health care infrastructure. Employees’ salary comprise 55 to 66 per cent of the budget, leaving little room for technological advancement, equipment and medicines.

Integration of mental healthcare in ailing primary care system is a difficult issue which may seem feasible for countries with well-established primary healthcare system. Nearly half a decade of research on pathways to psychiatric care in Pakistan has shown different, yet interesting trends.

For example, a pathway to psychiatric care study from a tertiary care hospital demonstrates that among 96 patients, only 2.8 pre cent were referred by primary care physician as opposed to 20 per cent referral from specialists in other fields of medicine. In this study 63 per cent cases were self/family referred. Only 17 per cent patients had a primary care physician. Clearly, the expected model of primary to tertiary referral care appears to be lacking at a practical level. In this study the principal referral path in Pakistan appeared to be word-of-mouth rather than primary care.

A substantial time period is lost before initiation of treatment in schizophrenia, which is labelled as duration of untreated psychosis (DUP). In the absence of a well-developed primary healthcare system, a majority of patients visit psychiatrists as their first contact. Time is lost due to non-recognition of prodromal symptoms and subsequently, inadequate treatment. Primary care system, which is competent and motivated, needs to be created while specialists must play their role in training and supervising this mass of generalists.

The prevalent apathy in public and private sector is primarily because of lack of awareness and the stigma related to mental illnesses; a perception which needs to be changed. An active public-private partnership could be a workable solution for mental health service provision. This requires a unified agenda and commitment from both tiers. Any lasting solution must address the deep rooted inequities, ethical misconducts and macroeconomic issues.

River of Life

Civilization has advanced at such a pace, over the course of century that it has put man out of touch with himself. We see countless, running hither and thither, trying to achieve peace of mind and spending millions in the process. However, this is of no Vail. 

 

Annals of History reports that Siddhartha, the enlightened Buddha was meditating besides a river when he achieved Nirvana. He came to sudden realization that water is one continuous being; one that has passed on, while the one that is yet to come is one – so is rest of the life force. All emanates from a fountain of infinite life. Off course, years of search and earnest yearning preceded this insight.

 

River teaches us lesson of constant growth and movement towards life’s maturity; to remain still is to stagnate. This incessant struggle towards its objective is some thing which inspires human beings towards self-actualization. Streams have different flow in different areas; as if stones infuriate them by pinching and pricking. However water flows through them with greater fervor. The water that emerges through is brighter, clearer and frothy white – displaying its true nature. At other places it flows leisurely, with sobering calmness and at peace with its surrounding.

 

Obstacles towards one’s objectives should be handled similarly to river; to bypass minor objects without much fuss, while tearing down any thing which stands in its way. Fools and ignorant are similar to small stones in the path of river, to be ignored and passed with compassion. Bigger blocks are to be passed by changing one’s tactics and movement. Only the biggest one are worth the fight, for river is a creative life force, replenishing all that is good and essential. It must fight the good fight with courage and wisdom[1].

 

Stones also seem to have distinctive shapes, exemplifying human character and personalities; sharp one, flat one, big one, small one. All seem to have a place in scheme of things. Some sit on the way side, as if waiting for the destiny to lay bare the course of their path. My soul seems to whisper, ‘wait for your destiny to unfold according to God’s plan’.

 

If city life is about alliances for mutual interests, then wise among men build it on wisdom and forthrightness. Small brooks, rivulets flowing leisurely with melodious sound, chirping of birds, abundance of crops in the fields, shadowy clouds and towering mountain peeks, all speaks of God’s mercy.

 

Cameras and photographs cannot behold the panoramic view; human mind and spirit is the true witness to His magnificence. Rivers and mountains serve to build the spirit within, redefining purpose and meaning. If one observes a towering mountain peak, embraced by silky clouds, romanticizing with the sunlight, giving a panoramic view for all to enjoy; soul take newness from such surroundings. Majesty Mountains bow down in obedience in front of Him. None had the vibrancy to be the witness of his grace, beauty and might – except the creature called Man. It is with ignorance as well as insight that he beckons these thought in his mind and soul.

 

He teaches each towards wholeness, through different means. For some ever flowing river, pine tress rather a chorus of pine trees, placed in an orderly manner, as if carpeting the rugged mountains, in love and awe for a divine guest, are a beckon towards His grace.  Just as tree grows so does human understanding; dyadic thoughts, laden with fruits of wisdom. To be the tallest in the forest, one has to be a beckon of hope. To bear all things, be the farthest in the forest, also takes time and understanding. 

 

There is no conflict in the nature, the beauty of all things, basking under the loving Sun. Similarly there is no denying the presence of omnipresent God. The more one accommodates this belief, the more orderly one’s life grows. Individual life is supported by an infinite spirit, which is constantly replenishing it. To open one self to this spirit of infinite peace, power, wisdom is to have abundant life. To close one self to this spirit is to have stunted, self serving life, which is un-gratifying.

 

We see number of people, spending millions, trying to attain peace of mind. If peace is to be found, it is within. In recognizing the oneness with this spirit of infinite life and opening oneself to its flow, one becomes whole.

In the words of enlightened Emerson ‘Place yourself in the middle of the stream of power and wisdom which animates all whom it floats, and you are without effort impelled to truth, to right, and a perfect contentment’.

 

Every thing in the material has a counterpart in the spiritual domain; former is the effect while later is the cause. The flagrant beauty of a lake, giving way to beautiful rivers is just one metaphor of life emanating from the God – the omnipresent. Realization of these facts, a fundamental change in the world view, leads towards greater satisfaction in life.  

 

 

 

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[1] By the bank of River Kunhar, Kaghan.