Refugee Review Tribunal AUSTRALIA

RRT RESEARCH RESPONSE

Research Response Number: PAK35608 Country: Date: 23 October 2009

Keywords: Pakistan – Women living alone – Mental in Pakistan – Availability of carers

This response was prepared by the Research & Information Services Section of the Refugee Review Tribunal (RRT) after researching publicly accessible information currently available to the RRT within time constraints. This response is not, and does not purport to be, conclusive as to the merit of any particular claim to refugee status or asylum. This research response may not, under any circumstance, be cited in a decision or any other document. Anyone wishing to use this information may only cite the primary source material contained herein.

Questions 1. What support is available for women living alone in Pakistan? 2. What psychiatric help is available for women living alone in Pakistan? 3. What is the availability of carers in Pakistan for women suffering problems?

RESPONSE

1. What support is available for women living alone in Pakistan? - support - Police support

Difficulties Associated with Women Living Alone in Pakistan

The Immigration and Refugee Board (IRB) of Canada’s December 2007 research response PAK102656.E - Pakistan: Circumstances under which single women could live alone examines the difficulties face when attempting to live alone. The following extract provides a perspective from an unnamed “adjunct professor of gender studies and international politics at the University of Denver who has worked for the past ten years with women’s and human rights groups in Pakistan.” According to the Professor, “[y]oung unmarried/divorced women in all classes in urban areas find it difficult to live alone. They cannot get apartments to be rented. If they own a property, they can more conveniently opt to live alone but again there is social pressure around them and they have to face all kinds of gossips and scandals”:

It is very hard for a single woman to live alone both in urban and rural areas. ... It depends on age, class, education, and urban or rural setting. Young unmarried/divorced women in all classes in urban areas find it difficult to live alone. They cannot get apartments to be rented. If they own a property, they can more conveniently opt to live alone but again there is social pressure around them and they have to face all kinds of gossips and scandals. In such case, age is their biggest problem. Older women can live alone but still they feel insecure socially and physically. We do have examples now in the big cities where highly educated and economically independent women opt to live alone but their percentage is very low. In the rural areas they mostly live with joint family even if they do not get along with them (Immigration and Refugee Board of Canada 2007, PAK102656.E – Pakistan: Circumstances under which single women could live alone, 4 December http://www2.irb- cisr.gc.ca/en/research/rir/index_e.htm?action=record.viewrec&gotorec=451597 – Accessed 21 October 2009 – Attachment 1).

The IRB response also contains the perspective of “a representative from an NGO specialising in women’s issues, specifically with regards to women affected by Islamic laws and customs.” Among the various statements made, the specialist argues that although it isn’t illegal for women to live alone, there are obstacles for women trying to rent on their own and “cultural pressures and personal security would continue to be issues, especially if it was common knowledge [that] a woman was living alone”:

After having lived in Pakistan for one year, the Representative stated that she had only encountered one woman living alone; the Representative explained that this woman was able to live alone because she was an activist, was aware of her rights and understood the cultural system which permitted her to ‘navigate daily challenges’. She added that she was aware of other women who had tried to rent apartments on their own but were unable to do so because of resistance from landlords who assumed they were planning to open a brothel. The Representative specified that it is also rare for men to live alone in Pakistan because people are expected to live with their families until they get married and set up households of their own. The Representative added that even though it is not illegal for women to live alone, there would be obstacles for a woman to try to rent an apartment or house on her own and “cultural pressures and personal security would continue to be issues, especially if it was common knowledge [that] a woman was living alone” (Immigration and Refugee Board of Canada 2007, PAK102656.E – Pakistan: Circumstances under which single women could live alone, 4 December http://www2.irb- cisr.gc.ca/en/research/rir/index_e.htm?action=record.viewrec&gotorec=451597 – Accessed 21 October 2009 – Attachment 1).

PAK102656.E also quotes a professor of law at the University of Warwick “who specializes in women’s human rights and gender and the law” and “has written various publications on Pakistan”. The professor states that in Pakistan “society…frowns upon women living on their own and would not help the reputation of the single woman.” Furthermore, “[t]he government has no services it can provide to support anyone without resources such as housing, etc”:

Generally, it would be accurate to say that single women are rarely able to live on their own without a male member of the family in Pakistan. Reasons for this are numerous but they primarily stem from custom and culture that requires a woman to have a male family member to be in a protective and supervisory role. Society also frowns upon women living on their own and would not help the reputation of the single woman. You may find one in a million single woman who has the means and can live in a big city with helpers, etc. to assist and protect her. This of course is a minority and an exception rather than the rule.

Regarding relocation, it is important to bear in mind that for relocation you need money and resources. The government has no services it can provide to support anyone without resources such as housing, etc (Immigration and Refugee Board of Canada 2007, PAK102656.E – Pakistan: Circumstances under which single women could live alone, 4 December http://www2.irb- cisr.gc.ca/en/research/rir/index_e.htm?action=record.viewrec&gotorec=451597 – Accessed 21 October 2009 – Attachment 1).

The IRB quote a “representative of Shirkat Gah Women’s Resource Centre” on the issue of livelihood options for single women without “appropriate qualifications”, stating that “they are trapped in the vicious cycle of cheap labour and often face sexual harassment.” On the subject of hostels for single women in , the representative states that the city has “only two working women’s hostels and very few private ones”:

Single women living alone also have to look for livelihood options (e.g. paying for house rent etc.) and in instances where they do not have appropriate qualifications, they are trapped in the vicious cycle of cheap labour and often face sexual harassment. But within present contexts, [the] majority of young educated women from remote areas come to main cities for better employment opportunities. They face a number of challenges including lack of working women hostels, procedural complications in getting admission and negative societal attitudes towards these women hostel[s]. In Lahore (second largest city of Pakistan) alone where government estimates now put the population at somewhere around 10 million, there are only two working women hostels and very few private ones. Also moving out alone on public transportation is one of the greatest challenges. Talking to a young woman living in the Government Hostel, one finds that these women have to deal with a variety of pressures ranging from non-acceptance from immediate family members to harassment from male bus drivers, vendors etc (Immigration and Refugee Board of Canada 2007, PAK102656.E – Pakistan: Circumstances under which single women could live alone, 4 December http://www2.irb- cisr.gc.ca/en/research/rir/index_e.htm?action=record.viewrec&gotorec=451597 – Accessed 21 October 2009 – Attachment 1).

Disability and Unemployment Benefits in Pakistan

A 2008 Pakistan Institute of Development Economics paper entitled ‘Pension & Social Security Schemes in Pakistan: Some Options’ indicates in Table 3 – Social Security Contingencies Covered and Types of Schemes in that disability (invalidity) pensions in Pakistan are accessible via social insurance rather than a publicly-funded social security system; “[t]he social safety nets are heavily favourable to the workers in the urban formal sector whereas the majority of the population lives in rural areas and [are] employed in the informal sector.” According to the paper, such schemes are financed by contributions made by employers and schemes that provide various non-old age pensions, known as ESSIs, cover 850,000 people in Pakistan. For people outside these schemes, in the ‘informal sector’, assistance is provided by “civil society organisations such as mosques, financial institutions, non-governmental organisations, and private philanthropists which are involved in the distribution of social services besides government institutions”:

In Pakistan, social security and pension schemes sponsored by the government benefit a small proportion of the population in the formal sector, even though a number of programmes are in place. For workers employed in the informal sector, there are civil society organisations such as mosques, financial institutions, non governmental organisations, and private philanthropists which are involved in the distribution of social services besides government institutions. There is however no umbrella institution to coordinate the services provided by these institutions for better coverage and delivery. The social safety nets are heavily favourable to the workers in the urban formal sector whereas the majority of the population lives in rural areas and employed in the informal sector. A view of the pension and social security schemes operating in Pakistan is presented and discussed in the following section.

… Pension and social security in the formal sector is currently provided through social insurance programmes and other employer benefit schemes. The current schemes can be divided into two main categories: The first category consists of the “general” or “by default” schemes. These are the government schemes that employers are required to contribute to, unless they have been specially exempted by legislation. The Employees Old Age Benefits Institution (EOBI) is a federal body that provides age, disability and survivors pensions. The Employees Social Security Institutions are provincial bodies (ESSls) that provide health services and some cash benefits to retired and senior citizens. The EOBI covers approximately 1.3 million workers, while the ESSls cover only 850,000 (Mahmood, N. & Nasir, Z.M. 2008, ‘Pension & Social Security Schemes in Pakistan: Some Options’, Pakistan Institute of Development Economics http://www.pide.org.pk/pdf/Working%20Paper/WorkingPaper-42.pdf – Accessed 21 October 2009 – Attachment 2).

The International Social Security Administration’s report ‘Social Security Programs Throughout the World: Asia and the Pacific 2008 – Pakistan’ also states that disability pensions in Pakistan are provided by a social insurance scheme, adding that such a pension amounts to “50% of the insured’s average monthly earnings in the last 12 months multiplied by the number of years of covered employment.” The report also states that no unemployment benefits are provided in Pakistan:

Old Age, Disability, and Survivors Regulatory Framework First law: 1972, never implemented. Current law: 1976 (old-age benefits), with 2008 amendment. Type of program: Social insurance system.

…Disability pension: The pension is calculated as 50% of the insured’s average monthly earnings in the last 12 months multiplied by the number of years of covered employment.

…No statutory unemployment benefits are provided (International Social Security Administration 2008, ‘Social Security Programs Throughout the World: Asia and the Pacific – Pakistan’, http://www.ilo.org/dyn/natlex/docs/CTRYPROFILE/DOCUMENTS/PAK/F286649718/Pakis tan.pdf – Accessed 21 October 2009 – Attachment 3).

Police Protection

In 1994 Prime Minister Benazir Bhutto opened the first female-only staffed police station in Pakistan in . The US Department of State’s Country Reports on Human Rights Practices for 2008 – Pakistan says that the number of such police stations in Pakistan expanded in 2006 however these stations reportedly remained under-resourced:

In 2005 authorities expanded the number of special women’s police stations with all female staff in response to complaints of custodial abuse of women, including rape. The Aurat Foundation reported these stations did not function properly due to lack of resources and lack of appropriate training for policewomen. Court orders and regulations prohibit male police from interacting with female suspects, but male police often detained and interrogated women at regular stations.

…The government operated the Crisis Center for Women in Distress, which referred abused women to NGOs for assistance. There were approximately 70 district-run shelter homes and approximately 250 facilities operating as ad hoc emergency shelters for women in distress, including female police stations and homes run by the provincial Social Welfare departments. The district-run centers provided shelter, access to medical treatment, limited legal representation, and some vocational training (US Department of State 2009, Country Reports on Human Rights Practices 2008 – Pakistan, Section 1.C – Attachment 4).

The UK Home Office’s Pakistan Country Assessment, published in April 2009, quotes information produced by Pakistan’s Ministry of Women Development on the subject of women’s crisis centres in Pakistan. The report states that ten women’s crisis centres were operating in Pakistan as of July 2006 and provide a range of services including counselling, legal aid and micro-credit:

23.56 On the subject of women’s crisis centres, the website of the Ministry of Women Development, last updated in July 2006, stated that 10 such centres were in place in Islamabad, Lahore, Sahiwal, Vehari, , Mianwali, Peshawar, Kohat, Quetta and . In addition 10 crisis centers are to be established in , , , Hyderabad, Mirpur, Sibi, Abottabad, Multan, Mirwala and . The centres were being run with local NGOs. The site also provided a list of services provided by the centres:

• Medical aid • Legal Aid • Social Counselling • To investigate cases of violence/case history • Establishing linkages with law enforcing agencies/police complaint cells • Training of micro-credit entrepreneurship • Rehabilitation through micro finance • Provision of interest free credit up to Rs. 15000/- in each case” [29h] (Crisis Centre – Shelter Home)

23.57 However an article in the Inter Press Service News Agency dated 8 March 2007 reported that help centres to assist women “…were established and managed by the federal ministry of women development (MoWD) in different cities ‘to provide relief/support on emergent [sic] basis and rehabilitate the survivors of violence and women in distress’ …The fact that these centres have been opened shows the government does acknowledge an important human rights issue though implementation is poor” (UK Home Office 2009, Pakistan Country Assessment, 16 April – Attachment 5).

The Thaindian News reported in July 2008 that Pakistan’s first female-only police station’, opened by Benazir Bhutto in Islamabad in 1994, was to close due to a lack of trained staff and legislative deficiencies. The report states that “only a police officer of the rank of inspector can investigate the complaints and cases filed with the police. Since no female officer of that rank existed, all the cases filed with the Islamabad women police station were investigated by male police officers, defeating the very purpose of setting up women police stations”:

…The scheme to set up women-only police stations in Pakistan seems to have fallen flat, as the first police station inaugurated by late Prime Minister Benazir Bhutto in Islamabad, on January 25, 1994, today stands shut down for lack of proper trained female staff to run it.

After 14 years, the City Police formally ordered the women-only police station last October to stop registering cases. By October 31, 2007, when the police station closed its register, it had registered a total 69 cases in the year.

…Women police stations were supposed to provide the persecuted women in Pakistan’s conservative, male-dominated society, a safe way to report their grievances to police. That such stations were needed was widely agreed as woman victims feel uncomfortable discussing rape and other abuses with male police. It also opened a window for women discriminated against in education, employment and legal rights.

But, the good scheme fell flat as no female police personnel were trained for the professional tasks. A woman sub-inspector of police had to be appointed SHO of the symbolic police station opened in Islamabad when the rules required an officer of the rank of inspector or above in the post.

Similarly, only a police officer of the rank of inspector can investigate the complaints and cases filed with the police. Since no female officer of that rank existed, all the cases filed with the Islamabad women police station were investigated by male police officers, defeating the very purpose of setting up women police stations (‘Paks first women-only police station consigned to history’ 2008, Thaindian News, source: ANI, 29 July http://www.thaindian.com/newsportal/business/paks-first-women-only-police-station- consigned-to-history_10077213.html – Accessed 22 October 2009 – Attachment 6).

In an April 2009 report in The Nation entitled ‘Women desk recommended in every police station’, Islamabad’s female-only station appears to have remained open, however a “negligible budget was allocated to the upkeep and maintenance of WPS and even…funds were required for stationary and provision of food to those in the lockup.” Furthermore, “the present building is actually a sewing centre of Capital Development Authority (CDA) and hence is given to the women police on ad hoc arrangement (Tirmizi, M. 2009, ‘Women desk recommended in every police station’, The Nation, 26 April http://www.nation.com.pk/pakistan-news-newspaper-daily-english- online/Regional/Islamabad/26-Apr-2009/Women-desk-recommended-in-every-police-station – Accessed 22 October 2009 – Attachment 7).

2. Psychiatric help available for women living alone in Pakistan 3. Availability of carers in Pakistan

According to the World Health Organisation Mental Health Atlas 2005 Pakistan spends “0.4% of the total health budget on mental health.” In goes on to report that as a consequence, the main sources of funding for mental health care are “out of pocket expenditure by the patient or family” and “social insurance and private insurances”. The Atlas states that there are “approximately 2000 primary care physicians and 42 000 primary care workers” trained in Pakistan, however there are no mental health training facilities for social workers. The Atlas does mention the existence of ‘community workers’, however it does not specify whether these workers have specific mental health training or function as part-time or full- time carers. The Atlas does state that “multiple training manuals for physicians, paramedics, community workers and teachers have been developed”:

National Mental Health Programme A national mental health programme is present. The programme was formulated in 1986. The national mental health programme is a part of the general health policy of the country and is aimed at incorporating mental health in primary care, removing stigma, caring for mental health and substance abuse across the country and maintaining principles of equity and justice in the provision of mental health and substance abuse services. It was fully implemented in 2001. It does not have a specific reduction plan.

National Therapeutic Drug Policy/Essential List of Drugs A national therapeutic drug policy/essential list of drugs is present. It was formulated in 1997.

Mental Health Legislation In February 2001, a new mental health ordinance 2001 was enacted. The new ordinance puts emphasis on promotion of mental health and prevention of mental illness. It provides encouragement to community care and proposes the establishment of powerful federal mental health authority by the Government. It provides protection of the rights of the mentally ill and promotion of the mental health literacy. It also provides the guidelines for the development and establishment of new national standards for the care and the treatment of patients. Informed consent for treatment and investigations can be obtained from the patient or his/her relatives.

The latest legislation was enacted in 2001.

Mental Health Financing There are budget allocations for mental health. The country spends 0.4% of the total health budget on mental health. The primary sources of mental health financing in descending order are out of pocket expenditure by the patient or family, tax based, social insurance and private insurances. The country has disability benefits for persons with mental disorders. Disability benefit is paid to individuals who are not able to work due to mental illness.

Mental Health Facilities Mental health is a part of primary health care system. Actual treatment of severe mental disorders is available at the primary level. The programme has initially started in , the largest province, in 1985 and is being extended to others over the years. There are many residential and day-care facilities, especially for people with learning disabilities providing social, vocational and educational activities.

Regular training of primary care professionals is carried out in the field of mental health. Training programmes have started in the province of Punjab as a part of in-service training for primary care personnel. Till now, approximately 2000 primary care physicians and 42 000 primary care workers have been trained. Community activists from NGOs (e.g. National Rural Support Programme (NRSP) are also being trained. Though there are training programmes for physicians, nurses and psychologists, there are no such facilities for social workers. Mental health training has been included in the programme of the District Health Development Centres.

The Institute of Psychiatry Rawalpindi Medical College was the first WHO collaborating Centre-EMR and is acting as a resource centre at national and regional level for training, services information system and research. Multiple training manuals for primary health care physicians, paramedics, community workers and teachers have been developed. In an additional training package on counselling skills for health professionals, a package for rehabilitation of mentally ill has been developed…

There are community care facilities for patients with mental disorders. The community mental health programme was planned in a phased manner. The first phase included collection of data pertaining to demographics, knowledge, attitudes and beliefs about mental health and sensitization of the community towards mental health. The second phase involved training of personnel in mental health. The third phase involved stimulation of community activities through advocacy campaigns using religious leaders and developing a workable referral system. In the final phase, qualitative changes were incorporated in the services and steps were taken to improve the knowledge of the population about mental health. The programmes have been initiated in all provinces but have not been generalized to the whole population. More than 78 junior have been trained in community mental health to act as resource persons in the development of programmes in their areas (World Health Organisation 2005, ‘Mental Health Atlas’, WHO website http://www.who.int/mental_health/evidence/atlas/profiles_countries_n_r1.pdf – Accessed 21 October 2009 – Attachment 8).

An article entitled ‘Pakistan’s forgotten patients’ by Samira Shackle, published in October 2008 in the New Statesmen provides a critical perspective on the level of care provided to mental health sufferers in Pakistan. In the article Ms Shackle quotes an anonymous on the quality of health care treatment and facilities in Pakistan. The psychiatrist concludes his/her statements with the opinion that “there is a shocking level of ignorance and moral suspicion of the mentally ill, even among those who work in the hospitals”:

“ECT [electro-convulsive therapy] is frequently administered unnecessarily or inappropriately, which can be life-threatening. It is not uncommon for nurses to literally chain patients to beds and leave them festering in urine-soaked sheets. Some workers in these facilities are doing the best they can, but many purporting to be psychiatrists are insufficiently qualified. Even in private hospitals, there is no regulation, so potentially dangerous cocktails of drugs can be prescribed. There is a shocking level of ignorance and moral suspicion of the mentally ill, even among those who work in the hospitals.”

Samira Shackle argues that despite the replacement of the 1912 Lunacy Act with a new mental health act in 2001, “the government has made no attempt to implement the vague aims of the ordinance” and that the “Federal Mental Health Authority disbanded in 2005 – having met just once.” Ms Shackle also claims that a nexus exists between government failures and a rising suicide rate in Pakistan; “[t]hese failures are matched by a dramatic rise in the number of over the last decade. There are no official records, due in part to stigma which persists in a country where attempted suicide remains illegal. Research conducted by the Aga Khan University, however, estimated that there are between 6000 and 8000 suicides per year. The World Health Organisation puts the number closer to 15000”:

According to human rights campaigners and mental health workers, the Pakistani government’s refusal to enact changes to mental health legislation constitutes a serious breach of human rights. The 2001 Mental Health Ordinance replaced the notorious 1912 Lunacy Act; updating the terminology surrounding mental illness, introducing rules to prevent mistreatment, and establishing the Federal Mental Health Authority.

But according to the Human Rights Commission of Pakistan (HRCP), and leading psychiatrists, the government has made no attempt to implement the vague aims of the ordinance. Despite guidelines by the World Health Organisation on the need for monitoring to protect against degradation, the Federal Mental Health Authority disbanded in 2005 – having met just once.

… “Changes to the law have had absolutely no impact,” says Dr Murad Khan, professor of psychiatry at the Aga Khan University in Karachi. “It’s a positive step, but none of it has been acted upon. On the ground, people are treated in exactly the same way.”

Dr Ghaus Mohammad, chairman of the Board of Visitors, confirms this, explaining that his attempts to communicate with the federal health minister on reform strategies have failed to elicit any response.

These failures are matched by a dramatic rise in the number of suicides over the last decade. There are no official records, due in part to stigma which persists in a country where attempted suicide remains illegal. Research conducted by the Aga Khan University, however, estimated that there are between 6000 and 8000 suicides per year. The World Health Organisation puts the number closer to 15000 (Shackle, S. 2008, ‘Pakistan’s forgotten patients’, New Statesman website, 22 October http://www.newstatesman.com/human- rights/2008/10/mental-health-pakistan-rights – Accessed 21 October 2009 – Attachment 9).

Amin A. Muhammad Gadit of the Memorial University of Newfoundland, writing in the Journal of Medical and Biological Sciences in 2007, presents a mixed picture of the state of mental . Gadit suggests that the private sector has boosted capacity in Pakistan; “The total estimated number of beds in private sector of the country are approximately 2000”, adding that a “private psychiatrist’s fee would range from Rs. 200 ($3.5) to Rs. 2000 ($35) per consultation.” Furthermore, “the major typical and atypical psychotropic medications are easily available”. On the subject of trained mental health professionals in Pakistan, Gadit reports that “at the moment there are 250 – 300 psychiatrists available in the country”, however “the recent brain drain has caused a blow to the existing services. There are 125 psychiatric nurses, 480 mental health care psychologists and 600 mental health care social workers.” Gadit concludes by stating that “[i]n view of poverty, low health budget, high cost of medicines there is huge economic burden on the patients. The hospitals also don’t follow the intake/admission criteria, no separate unit for subspecialties, no appropriate long stay units, no exit/discharge criteria, no rehabilitation services, no exchange of information between psychiatrists and family practitioners, no proper advertisement of available services, no concept of day centers, day hospitals, ill developed community services, no central registry of patients and set policy for management systems in the psychiatric set ups and finally no internal referral system”:

At the moment, there are about 2,940 psychiatric beds available with the public sector while private sector in Karachi, which is the largest city, the number of existing psychiatric beds is 4529. The total estimated number of beds in private sector of the country are approximately 2000.Significant improvement in services was witnessed especially in Lahore where the old Lahore Mental Hospital was re-designated as a full institute, Sir Cowasji Institute at Hyderabad was elevated to a teaching hospital and major teaching hospitals were upgraded. Peshawar also made some progress over the years, while Quetta (Baluchistan) remained mediocre. Karachi (Sindh) has shown significant progress in private sector with active psychiatric units. One such unit was instrumental in bringing a revolutionary change in terms of awareness raising and referral. Many other non-governmental organizations started psychiatric services at very nominal or no cost at all which gave great boost to the services. Some of these services include free provision of medications. With the help of private sector, services are now easy to avail and there is no waiting time unlike that in many developed countries. The private psychiatrist’s fee would range from Rs. 200 ($3.5) to Rs. 2000 ($35) per consultation. The major typical and atypical psychotropic medications are easily available. The brand products are very expensive while the me-too products and those produced locally are relatively affordable. Over the years, psychiatric man power increased in number though still far from adequate for such a large population. At the moment there are 250 -300 psychiatrists available in the country. The recent brain drain has caused a blow to the existing services. There are 125 psychiatric nurses, 480 mental health care psychologists and 600 mental health care social workers. A large number of psychiatric patients are seen by family practitioners and alternate therapists and only 5-10% of the patients reach the psychiatrist mainly for the reasons of stigma, low awareness and cost factors. Regarding the different types of psychiatric services, forensic psychiatry is almost non-existent, very small number of child psychiatrist, practically few psychotherapists, and no geriatric, addiction, rehabilitation, learning disability or liaison psychiatrists.

…There is also acute shortage of allied mental health professionals. In view of poverty, low health budget, high cost of medicines there is huge economic burden on the patients. The hospitals also don’t follow the intake/admission criteria, no separate unit for subspecialties, no appropriate long stay units, no exit/discharge criteria, no rehabilitation services, no exchange of information between psychiatrists and family practitioners, no proper advertisement of available services, no concept of day centers, day hospitals, ill developed community services, no central registry of patients and set policy for management systems in the psychiatric set ups and finally no internal referral system (Gadit, A.A.M. 2007, ‘Psychiatry in Pakistan: 1947-2006 – A New Balance Sheet’, Journal of Medical and Biological Sciences, Scientific Journals International, Volume 1, Issue 2 http://www.scientificjournals.org/journals2007/articles/1111.pdf – Accessed 21 October 2009 – Attachment 10).

A November 2007 article entitled ‘Millions lack access to mental healthcare’, published by Integrated Regional Information Network (IRIN) reports that “there is only one psychiatrist for every 10,000 people in Pakistan, one child psychiatrist for four million children estimated to be suffering mental-health issues and only four major psychiatric hospitals and 20 such units attached to teaching hospitals”:

There are no exact numbers for the mentally ill in Pakistan, due largely to the associated stigma, but some estimates put the figure at more than 14 million people, out of a population of some 160 million.

Speaking at a seminar to mark World Health Day in October, Ijaz Haider, of the Allama Iqbal Medical College in Lahore, reported that “mental problems had increased from 6 percent to 9 percent in the population in the past decade”.

And while comparisons with other countries are difficult as no official reports are made to the World Health Organization, Syed Haroon Ahmed, of the Karachi-based Pakistan Association for Mental Health (PAMH), told IRIN: “Rates of mental illness in Pakistan are higher than in many other developing countries because of the uncertainty and insecurity here.”

…According to Lahore’s University of Health Sciences Vice-Chancellor Malik Hussain Mubashir, there is only one psychiatrist for every 10,000 people in Pakistan, one child psychiatrist for four million children estimated to be suffering mental-health issues and only four major psychiatric hospitals and 20 such units attached to teaching hospitals.

…In addition, the Mental Health Ordinance, introduced in 2001 to replace the Lunacy Act of 1912, remains poorly implemented, say specialists.

The ordinance attempted to introduce more enlightened psychiatric care, particularly in state- run institutions, and laid down rules to prevent the mistreatment of patients.

But little has come of it. Even at leading institutes for mental health, there are continued reports of patient mistreatment or a failure to provide adequate care.

…PAMH has reported that up to 44 percent of people, the majority women, were clinically depressed due largely to their marginalised status in society. Estimates are based on patients treated by PAMH and research into mental-health issues.

PAMH believes socio-economic factors are responsible for this, while the high rate of suicide, with 1,717 people taking their lives in 2006 alone, according to figures compiled by the Human Rights Commission of Pakistan, provides evidence of the extent of depression and desperation (Integrated Regional Information Network (IRIN) 2007, ‘Millions lack access to mental healthcare’, 8 November – Attachment 11).

Writing on education and mental , Rudina Xhaferri and Khalid Iqbal state that many people in Pakistan seek help for psychiatric/metal health issues from “homeopathic doctors, Hakims, and holy men”. Quoting a year 2000 study, Xhaferri and Iqbal state that most mentally ill people in Pakistan are cared for by their families and “as a consequence of home treatment without proper medical care, drug abuse and suicide rates have been rising in the recent years”:

Due to lack of information, awareness, and access to professional health services, the main sources of assistance for such patients are homeopathic doctors, Hakims, and holy men (pirs). Few people seek professional medical help. Naeem and Ayub (2000) have observed that in Pakistan, mentally ill patients are mostly cared for by their families. According to World Health Organisation statistics, about 46 per cent to 66 per cent of women and 15 per cent to 25 per cent of men in Pakistan, suffer from anxiety and depressive disorders (Mental Health Atlas, WHO, 2005). Emotional distress is associated with age, social disadvantage (in both genders) living in unitary households (in women), and lower education (in younger subjects). As a consequence of home treatment without proper medical care, drug abuse and suicide rates have been rising in the recent years. The Human Rights Commission of Pakistan reports that in 2006 alone, 1,717 people took their own lives, mainly because of deep depression and desperation. The Pakistan Association for Mental Health pinpoints the growing mental-health issues as a major contribution to suicide rates (Xhaferri, R. & Iqbal, K 2008, ‘Education – Specialising in mental health’, Promotion of (PEP) Foundation website http://www.pepfoundation.org/dawn9.pdf – Accessed 20 October 2009 – Attachment 12).

According to Haroon Rashid Chaudhry, writing in the October 2008 Pacific Rim College of Psychiatrists Bulletin, Fountain House in Lahore offers “state of the art rehab facility to the chronic psychiatric patients having following diagnosis: , Bipolar disorders, Drug induced Psychosis and puerperal psychosis”:

Fountain House (The Rehab Center) situated at 37 Lower Mall Lahore Pakistan is a project of Lahore Mental Health Association, established in December 1970 by Late Professor Emeritus Muhammad Rashid Chaudhry. The Association is registered with Directorate of Social Welfare Department, Government of the Punjab, Pakistan.

Fountain House is a rehab centre for the chronic psychiatric patients and over 3000 patients have received rehabilitation services so far. It also provides acute treatment for mentally ill. In 1981, Professor Muhammad Rashid Chaudhry introduced the concept of “House Members” for the patients of Fountain House and since then they are called as “Members”.

The ideology of the Fountain House is to restore the patient’s life in accordance with their aptitude, capacity and capability. Its basic objective is to rehabilitate the psychiatric patients and involve them in different activities that can contribute to full recovery. It also promotes excellence in mental health services through training, technical assistance, research and policy development.

Fountain house is the project mainly run by the community. Fountain house sections are providing state of the art rehab facility to the chronic psychiatric patients having following diagnosis: Schizophrenia, Bipolar disorders, Drug induced Psychosis and puerperal psychosis (Chaudhry, H.R. 2008, ‘Innovative Programs in the Region: Fountain House, Lahore-Pakistan – Model for the Developed Countries’, Pacific Rim College of Psychiatrists Bulletin, October, p.3 http://www.prcp.org/pdfs/PRCPBulletinOct2008final.pdf – Accessed 22 October 2009 – Attachment 13).

The Fountain House website indicates that the programmes and therapies are primarily geared for sufferers of schizophrenia, “Fountain House is a very unique institution of its kind in the field of mental health. At present the institution is catering to the needs of over four hundred schizophrenic patients (Khan, R.M. 2006, ‘Fountain House Report March’, Fountain House website http://www.fountain-house.org/visitors_desc.php?id=7 – Accessed 22 October 2009 – Attachment 14). The website does, however state that “Special Free Psychiatric services are offered to Psychiatric patients deprived of mental health services due to non availability of Psychiatrists” (‘Out Research Program – Reaching the Unreached’ (undated), Fountain House website http://www.fountain-house.org/programmes.html – Accessed 22 October 2009 – Attachment 15).

Internet Sources:

Government United States Department of State http://www.state.gov/ Department of Foreign Affairs and Trade http://www.dfat.gov.au Immigration and Refugee Board of Canada http://www.irb-cisr.gc.ca/ UK Home Office http://www.homeoffice.gov.uk/ Pakistan Ministry of Health http://www.health.gov.pk Pakistan Ministry of Women Development http://www.women.gov.pk/ Pakistan National Commission on the Status of Women http://www.ncsw.gov.pk/

United Nations (UN) UN http://www.un.org/ UNHCR http://www.unhcr.ch/cgi-bin/texis/vtx/home World Health Organisation http://www.who.int/

Non-Government Organisations International Crisis Group http://www.crisisgroup.org Amnesty International http://www.amnesty.org/ Human Rights Watch http://www.hrw.org/

Pakistan Media Pak Tribune http://www.paktribune.com/ Dawn http://www.dawn.com/ The Daily Times http://www.dailytimes.com.pk/ The Nation http://www.nation.com.pk/ Pakistan Observer http://pakobserver.net/ The News http://www.thenews.com.pk/

Topic Specific Pakistan Association for Mental Health http://www.pamh.org.pk/ Lahore Mental Health Association (Fountain House) http://www.fountain-house.org/

Search Engines Google http://www.google.com.au/ Alltheweb http://AlltheWeb.com

Databases: FACTIVA (news database) CISNET (DIAC Country Information database) REFINFO (IRBDC (Canada) Country Information database) ISYS (MRT-RRT Research & Information database, including Amnesty International, Human Rights Watch, US Department of State Reports) MRT-RRT Library Catalogue

List of Attachments

1. Immigration and Refugee Board of Canada 2007, PAK102656.E – Pakistan: Circumstances under which single women could live alone, 4 December http://www2.irb- cisr.gc.ca/en/research/rir/index_e.htm?action=record.viewrec&gotorec=451597 – Accessed 21 October 2009.

2. Mahmood, N. & Nasir, Z.M. 2008, ‘Pension & Social Security Schemes in Pakistan: Some Options’, Pakistan Institute of Development Economics http://www.pide.org.pk/pdf/Working%20Paper/WorkingPaper-42.pdf – Accessed 21 October 2009.

3. International Social Security Administration 2008, ‘Social Security Programs Throughout the World: Asia and the Pacific – Pakistan’, http://www.ilo.org/dyn/natlex/docs/CTRYPROFILE/DOCUMENTS/PAK/F2866497 18/Pakistan.pdf – Accessed 21 October 2009.

4. US Department of State 2009, Country Reports on Human Rights Practices 2008 – Pakistan.

5. UK Home Office 2009, Pakistan Country Assessment, 16 April. 6. ‘Paks first women-only police station consigned to history’ 2008, Thaindian News, source: ANI, 29 July http://www.thaindian.com/newsportal/business/paks-first- women-only-police-station-consigned-to-history_10077213.html – Accessed 22 October 2009.

7. Tirmizi, M. 2009, ‘Women desk recommended in every police station’, The Nation, 26 April http://www.nation.com.pk/pakistan-news-newspaper-daily-english- online/Regional/Islamabad/26-Apr-2009/Women-desk-recommended-in-every- police-station – Accessed 22 October 2009.

8. World Health Organisation 2005, ‘Mental Health Atlas’, WHO website http://www.who.int/mental_health/evidence/atlas/profiles_countries_n_r1.pdf – Accessed 21 October 2009.

9. Shackle, S. 2008, ‘Pakistan’s forgotten patients’, New Statesman, 22 October http://www.newstatesman.com/human-rights/2008/10/mental-health-pakistan-rights – Accessed 21 October 2009.

10. Gadit A.A.M. 2007, ‘Psychiatry in Pakistan: 1947-2006 – A New Balance Sheet’, Journal of Medical and Biological Sciences, Scientific Journals International, Volume 1, Issue 2 http://www.scientificjournals.org/journals2007/articles/1111.pdf – Accessed 21 October 2009.

11. Integrated Regional Information Network (IRIN) 2007, ‘Millions lack access to mental healthcare’, 8 November. (CISNET Pakistan – CX188058)

12. Xhaferri, R. & Iqbal, K 2008, ‘Education – Specialising in mental health’, Promotion of Education in Pakistan (PEP) Foundation website http://www.pepfoundation.org/dawn9.pdf – Accessed 20 October 2009.

13. Chaudhry, H.R. 2008, ‘Innovative Programs in the Region: Fountain House, Lahore- Pakistan – Model for the Developed Countries’, Pacific Rim College of Psychiatrists Bulletin, October http://www.prcp.org/pdfs/PRCPBulletinOct2008final.pdf – Accessed 22 October 2009.

14. Khan, R.M. 2006, ‘Fountain House Report March’, Fountain House website http://www.fountain-house.org/visitors_desc.php?id=7 – Accessed 22 October 2009.

15. ‘Out Research Program – Reaching the Unreached’ (undated), Fountain House website http://www.fountain-house.org/programmes.html – Accessed 22 October 2009.