A sane solution

It is a rainy day with dark clouds scudding across the sky; the biting cold numbs the fingers and nose. And around us, there is lush greenery. Against this backdrop, an elderly couple appears, with a smart looking youngster by their side. They are making their way into a building. The visibly fragile mother suddenly falls while climbing the porch stairs, but quickly gets herself up. Her young son, though standing close by, appears too preoccupied with his own thoughts to have noticed his mother’s fall. But as it turns out, we learn he is schizophrenic, seriously affected by his affliction.

This 18-year-old boy, Mohammad Sami, who hails from an impoverished locality of Latifabad-12, Hyderabad district, was brought by his old parents to consult a psychiatrist about his schizophrenia and fits at the Sir Cowasjee Jahangir Institute of Psychiatry & Behavioral Sciences, Hyderabad, popularly known as the ‘Pagalkhana.’

Sami seems perfectly well in terms of his appearance, but he, in fact, suffers from hallucinations and delusions due to his mental disorder. That aside, this young man, though illiterate and unemployed,  is a gentleman, with absolutely no guile. He talks about himself effortlessly, but is completely ignorant of his mental disease. His illness makes him an obvious burden on his impoverished family, who are unable to bear his medical treatment.  The Cowasjee Jahangir facility, from where he gets free-of-cost consultation and medicines every month, is thus a huge blessing for Sami’s family.

The Sir Cowasjee Jahangir Institute of Psychiatry & Behavioral Sciences, Hyderabad (SCJIPBSH), also known as Giddu Hospital, Chariyan Ji Aspatal, and the Pagalkhana, is the second-oldest facility in South Asia after the Ranchi Institute of Neuro-Psychiatry and Allied Sciences (RINPAS) in Bihar, India, also known as a lunatic asylum. And there is another mental health facility in Pakistan, the Punjab Institute of Mental Health (PIMH), called the Lahore Mental Hospital, which came a little later. All of these three lunatic asylums were established during the British Raj.

Mental health is now widely viewed as an integral part of healthcare, dealing with the essential and integral psycho-social and biological component of a comprehensive healthcare system. A psychiatrist discloses that currently every fourth person in the urban areas of Pakistan is suffering from a mental disorder, and this ratio is expanding furiously across the country.

Being the prime facility for mental healthcare across the Sindh province, the (SCJIPBSH) is a 500-bed hospital, and possesses a 50-bed ward for acute emergencies, a 100-bed ward for sub-acute ward conditions, a 100-bed custodian ward, a 100-bed ward for partially recovered patients, a 20-bed ward for drug addicted patients, a 50-bed ward for forensic psychiatry, a female ward comprising 30 beds and a 50-bed rehabilitation unit. Hospitalised patients with assorted mental disorders can avail healthcare facilities along with meals and laundry services at zero cost.

Sindh Mental Health Authority (SMHA) chairman, Senator Dr Karim Khwaja disclosed: “I am striving to legally upgrade this institute to the first Mental Health University of South Asia so that all the problems at the facility can be resolved on a priority basis, and it can facilitate all the mentally/psychologically challenged patients there with modern techniques.” At present, the degree-awarding Cowasjee Institute is affiliated with two top universities, including LUMS and the University of Sind, Jamshoro.

Dr Khwaja added that there is an acute shortage of psychiatrists in Pakistan — apparently there are only 500-550 in the country, and around 140 in Sindh.   A noted senior psychiatrist of the institute, Dr Jamil Junejo, who is part of several committees formed by the Sindh government to raise the Cowasjee facility said: “In 1952, when the Largactil (chlorpromazine hydrochloride) tablet was introduced, it brought about a kind of revolution for the treatment of severely psychotic patients. Many of them could now be treated at home or in other facilities, and did not require hospitalisation in lunatic asylums. People in the West started setting up fully-secure or semi-secure units of hospitals instead of building lunatic asylums.” However, in Pakistan Dr Junejo said, work on mental health legislation was sorely lacking. The Lunacy Act 1912, which had been implemented until 2001, left a lot to be desired. Then, the Mental Health Ordinance 2001 was introduced by Musharraf’s regime. This called for setting up 20-bed psychiatric units, each with a full- time psychiatrist and essential medicines, in every district of the country. And the two main lunatic asylums were to be upgraded to cater to the country’s expanding population, and the consequent increasing mentally ill populace.

The Downside

The institute is located in an upmarket commercial area, one of the city’s main business hubs, with several shopping malls, branded outlets and the well-known known Resham and Shahi bazaars of Hyderabad district. Not surprisingly then, members of Sind’s mainstream political parties and land grabbers have from time to time tried to encroach on the institute’s land under the guise of setting up a ‘government employees colony,’ a  ‘City General University’ and a housing scheme there. Eminent psychiatrist and Pakistan Association for Mental Health founder Professor Dr Syed Haroon has, however, put up stiff resistance to these scheme. Resultantly, they have not come about, but how long they will be deferred remains to be seen.

But there have been other encroachments. In 2004, the then health secretary allotted a 4,125 square yard plot for the construction of the College of Physicians and Surgeons Pakistan (CPSP)’S Hyderabad regional centre within the premises of the facility. And In 2018, a bungalow allotted to the head of the facility was allotted to the office of the Lady Health Workers (LHWs) programme for family planning and primary healthcare, by a written order issued by the Sind Secretary Health. Meanwhile, the institute is also saddled with two other informal encroachments it cannot rid itself of.

Well-placed sources familiar with the situation said that the institute has also been seeing an erosion of its efficiency and  losing efficacy, because of the machinations of vested interests, and due to the disinterest of the Sind government. This although the institute has been declared  a cultural heritage site and an autonomous body.

The Chief Executive Officer (CEO) of the institute and rights activist, Dr Aijaz Qadir Patoli, who has just recently retired, highlighted problems in connection with encroachments and other issues being faced by the hospital administration and patients.

“The Sind Chief Secretary has already given clear-cut directives about doing away with the illegal possession of the bungalow of the head of the institute, and has formed a committee in this and other regards, which includes the Sind Director General Health Services, the Hyderabad Divisional and Deputy Commissioners, and the CEO of the institute.

Simultaneously, he has also ordered the Vice Chancellor of the Liaquat University of Medical and Health Sciences (LUMHS) Jamshoro and the Divisional Commissioner to vacate the 4,125 square-yard given to the CPSP and move it to LUMHS.”

Dr. Patoli added that the Sind High Court Karachi and its circuit bench in Hyderabad have also called for the removal of any kind of encroachment in this regard. He said that the then Secretary Health had illegally allotted the bungalow and site for the CPSP as he has no rights to allot any part of the trust property (or institute).

“I have to face resistance from the locality, but I have succeeded in obliterating an encroachment on the street adjacent to the institute by land grabbers. The fear was that they might have encroached on the institute by knocking down the boundary wall,” said Dr. Patoli.

He added that he had also removed an encroachment by the Extended Programme on the Immunisation (EPI) cold chain divisional store of the old dining hall and the illegal possession of an NGO  from a 60-bed ward of the institute. Highlighting other problems and their solution, he disclosed that 30 percent of the fully recovered patients of the institute have been forced to live in the hospital as close relatives, even their parents, are reluctant to take them home. He said that the staff have to manipulate the safe return of their patients to their respective houses.

“Day before yesterday, the staff approached me with the story of a young girl who is currently not being accepted by her father and brothers, even though they are well-off. They are unwilling to allow her to live with them,” he lamented.

According to the Mental Health Act 2013, an assessment of an insane person should be conducted within 28 days, and his or her hospitalisation should not be for more than six months, but many patients remain in the hospital for years.

“The institute must be providing adequate human resources and even finances, so that many patients recover,” Dr Patoli said. But he pleaded for capacity building of the staff and infrastructure by upgrading it scientifically.

History of the asylum

The Cowasjee Institute, which is the only mental health facility in Sind, is a trust property. Spreading over 27 acres, it was set up by a Parsi philanthropist of Persian origin in 1865 as a lunatic asylum to help mentally ill persons. Sir Cowasjee Jahangir, who was a government contractor, civil engineer and above all a philanthropist, established the asylum when, after trips from his native city Bombay to Hyderabad Sind in undivided India, he saw mentally ill people aimlessly wandering around, scavenging for food littering the roads, and people jeering at them.

This prompted him to establish a place for such ill, abandoned people outside Hyderabad city, on the way to the port of Seth Giddu Mal, where many of these sorry individuals were visible. Hence the name Giddu Bander Hospital. This is situated near the Kotri section of the River Indus. Set up by Sir Cowasjee Jahangir, the asylum was also bankrolled by the then government. The facility became a mental hospital in the 1900s, was renamed the Sir Cowasjee Jahangir Institute of Psychiatry (SCJIP) in the 1980s, and finally, the Sir Cowasjee Jahangir Institute of Psychiatry & Behavioral Sciences Hyderabad (SCJIPBSH) in 2019.

Staff and various services offered by the SCJIPBSH

The 368-member staff of the hospital, led by a chief executive officer (CEO), includes 65 general doctors and psychiatrists, 25 nursing school staff, 43 additional nurses, 139 skilled staffers, 22 ministerial staff and 74 unskilled workers. The institute also has the support of another three senior psychiatrists of the Liaquat University of Medical and Health Sciences (LUMHS) Jamshoro. Each day 300-plus psychotic patients visit the OPD until 2 pm, and after that, approximately 30 patients come to consult doctors and psychiatrists during the centre’s round-the-clock emergency service.

Every in-patient receives free medicine and routine meals, which cost Rs 400 each, while a single outpatient gets free medicines worth Rs 700 for a month. The institute is funded by the Sind government in collaboration with a handful of local donors, and it has seen a regular increase in the number of outpatients — up to 17,000 in the last five years.

Services

The Psychiatric Emergency Service at the institute consists of 24-hour emergency management and admissions, an OPD (out-patient department), digital mental health service (WhatsApp), qualified and specialist service availability and minor OT (operation theatre) services.

Out-Patient clinics and services include specialist care, treatment for minor mental illness experience, counseling services, a narcotics detox clinic, and a child mental health clinic.

In-patient care encompasses a treatment facility for acutely ill patients, an ECT facility, radio diagnostics, a laboratory, co-morbidity services, an isolation facility, oral healthcare and a forensic unit. Education services comprise post-graduate DPM, MD, FCPS courses, and under-grad students can train in psychiatry. Under-grad and post-graduate students are also provided training in psychology, and the promotion of ethical research in mental health with a database facility. There is also in-service training for the staff and diverse speciality clinics have been set up by experts from other hospitals.

Rehabilitation services include a rehabilitation centre with skill development training, ward-based activities to empower clients with the skills needed for independent self-care, psychotherapy and occupation therapy, family and group sessions with clients and service providers, and sports and entertainments therapy.