Expanding Mental Health in Pakistan

BW: How are concepts of mental health accepted culturally?

KE: There is a cultural aspect to Pakistan which plays a positive role in the treatment and care of people with mental illness: First, people still live in joint families, which ensures that there are multiple caregivers. Second, Islamic belief inculcates a greater acceptance of mishaps and tragedies. In the absence of outside help, people are able to brave illnesses with more patience and forbearing than they would in the West. Third, larger average families tend to absorb the ill member better. There is a lesser danger of overinvolvement by the parents, and the individual is allowed to find his or her level at his or her pace, mostly without any professional or medical intervention.

BW: So what, if any, social stigma is associated with mental illness in Pakistan?

KE: The concept of mental health in Pakistan was closely related to lunacy. As a boy growing up, I heard many stories of relatives who had been taken over by Jinns or spirits. They were locked up in remote outhouses and never let out. Although some progress has been made since those days, the concept of Jinns and spirits taking over your body still widely exists.

A popular treatment is going to a priest, wearing holy amulets and drinking holy water. The harshest treatment, still carried out in villages, is to be tied to a tree outside the tomb of some local saint and then left there for days or weeks until the Jinn decides to leave your body or is ordered out by the dead saint.

BW: Does such stigma, fundamentalism, or any other cultural issue impact your ability to successfully treat patients?

KE: The treatment of mental illness does not face the same hurdles as, say, inoculation, which is resisted by some on pseudoreligious grounds. But people can frequently delay getting their family members proper medical treatment by taking them to mosques and other religious places for faith healing. By the time some patients reach the hospital, their cases may have become chronic.

BW: How are you funded? What financial support is necessary to your continued operation and growth?

KE: The hospital is mostly funded through donations. Three types of institutions have been extremely helpful in this and it was a big advantage to have on our board former chief executives of multinationals in Pakistan. Our main fundraising has four components: multinationals, the Rotary Club in Karachi, the Infaq Foundation — a prominent charitable foundation of Pakistan based in Karachi — and individuals, mostly in the form of zakat, which is an obligatory form of giving that Muslims practice — 2.5 percent of each Muslim’s savings each year [is donated to charity]. The total annual cost of running the hospital is $400,000. This is a lot for Pakistan, but nothing in relation to what it would cost to deliver the same services in the U.S. In the third world, a little goes a long way.

BW: How many people are you currently helping?

KE: Although Karwan has 100 beds for inpatients, it has a busy outpatient department which sees 10,000 patients a year, and a satellite clinic which sees another 5,000 patients a year.

BW: What are your goals for the future of your institution?

KE: My second sister, who lives in New Jersey, and I decided to import know-how from the U.S. and train the staff in concepts that were not available in Pakistan. We set up a 17-week training course in rehabilitation for Karwan and conducted it almost exclusively through Skype. Ten people graduated from the course. Professors from the university have traveled twice to Karachi to meet face to face with their students. This they did in spite of the risk to Americans because of the law-and-order situation in Pakistan.

Before this course, Karwan was hospitalizing people but had no idea what to advise them once the critical phase was over. The concept of rehabilitation, which is somewhat new even to the U.S., is based on three practices: illness management and recovery, family psychoeducation, and individual case management.

BW: What is your vision for mental health services in Pakistan, and the region, in an ideal future?

KE: During my last visit to Pakistan, in November 2009, I was able to start another project which had always been at the back of my mind: setting up a halfway house for the purposes of rehabilitation. This facility would be different from Karwan, not only in its concept, but also that it would be run exclusively by my sister and [me]. It would also be different in that aside from seed money it would be fully self-sustaining, as it would not cater to the poor and its fees would be based on recovering its costs.

Karwan had the choice to expand quantitatively or qualitatively and it chose to focus on quality for now. There are immense opportunities for opening satellite clinics across Karachi so as to make the service available to a greater number of people. But without adequately trained staff, the clinics could not offer good advice or treatment.

A lot of work is being done by private individuals, but the government is conspicuous by its absence. We now have possession of a six-bedroom house in Karachi, and within six weeks have been able to raise $25,000 of the $50,000 that we anticipate needing for seed money. None of the money has been raised from Karwan donors. The biggest challenge is how to manage a high-quality facility in Pakistan when we are in the U.S.

Clearly, a lot more work needs to be done to create awareness about mental health. This can be done by involving the media. There is also the need to develop local leaders and sponsors who are passionate about this subject. There are a lot of people involved who run NGOs in the area of health, but there are hardly any in the area of mental health. The fact that there will now be two models for them to emulate should make things easier.

We have also focused on getting the University of Karachi to offer [a] master’s in social work with an emphasis on psychology. There is a great need to turn out more nurses, psychologists, occupational therapists in the area of psychiatry. A greater awareness through the media may help to both mobilize the government and make more money available through donations.

I am not aware what international agencies like UNICEF and UNDP are doing, but they do not appear to be focused on mental health. The Gates Foundation does not work in Pakistan, perhaps because of the law-and-order situation. For the time being, this issue is left to individuals who are passionate about this subject.

This article is updated from its initial publication in Brain World Magazine’s print edition.

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