December Issue 2015

With four children lying strangled in grotesque forms on the floor, and one on the run, Subhagi had just moments to make a choice. Her husband was hunting for the final and their eldest child to kill and subsume. This, in the hope of ingesting his soul to consolidate his own power as a wizard, according to the instructions of a man commonly acknowledged as a quack.

What sounds like a bad science-fiction plot unravelled in this little hamlet of rural Matiari as the tragic reality Subhagi has to live with today.

She weighed the possibility of saving her son against the assured outcome of losing her husband. “He had been on drugs for so many years, I knew he didn’t think of his children as his children, he talked of drinking their blood. He had drugged me and tried to kill the children before, but my eldest son had managed to stop him. We thought it was the drugs, we didn’t realise there was a man pretending to be a priest, eating up our family income, promising him power,” she says.

Subhagi tells us that a few days before he committed the heinous crime, her husband had left the house. She begged him to come home, but he told her that he had finally met someone who believed in him, that he knew there was something powerful inside him which needed to be nurtured and guided.

“There were a few strange men of magic he went to, and he spent all the money we had on them. He would listen to them endlessly, and even stole to fulfil their demands for funds. Finally, one of them made him do what he did,” she says, her words dissolving into sobs. “Do you think you can find my eldest son and bring him back to me? Please, I’ve suffered so much.”

Subhagi is sitting on a charpai in her brother’s house, her hands fidgeting with the black chaddar she wears loosely over her tied hair. She makes this appeal to a group of NGO case workers who are on the premises trying to help her.

“It’s been six months, and my son won’t see me. He thinks I am responsible for his father’s death. I did tell the police where to find him, I did it to protect my son. His father was convinced he had to kill them all to attain power and would not have stopped. Please, please make him understand,” Subhagi pleads.

“He was addicted to many drugs, but was also mentally ill. No one understood that. Instead, those charlatans convinced him there was a demon living inside him that needed placating, that needed to be fed. So he sacrificed our children. But my in-laws refuse to accept why I had to call in the police,” she continues.

“I only begged the police to restrain him, to save my son,” she says. “The police say he was killed in an ‘encounter’ — that he resisted arrest, and they opened fire.” Subhagi’s in-laws, on the other hand, claim she bribed the police to slay her husband.

The fact is that it wasn’t Subhagi who first saw the bodies sprawled across the floor — she wasn’t even home. She had earlier been sent to her parents’ home by her husband, presumably so he could drug and strangle the children at his convenience. It was her sister-in-law who alerted the family to the travesty and that’s when Subhagi came running home.

“He wanted me out of the way. He tried to drug me with sleeping potions in my tea, nashay ki dawa ghool di thi, but it didn’t work, so he had to remove me to do the job,” she says.

Subhagi recounts how, a few days before the final horrific episode, her eldest son had caught his father trying to strangle his youngest sister. The boy had become hysterical. The 14-year-old wrestled his father to the ground, while the daughter wriggled out of her deranged parent’s grasp.

One week later, he sent Subhagi to her parent’s house, and his eldest son to his father’s house, and started to implement his plan.

Subhagi turns to her brother and entreats him to reunite her with her son. He appears exasperated. Her aunt slips a supportive arm around her shoulders, but her brother rolls his eyes, warning her to be silent. Subhagi’s in-laws had been on the verge of declaring a blood feud against Subhagi’s family, and that, everyone knew, would consume the lives of too many able-bodied men from both families.

“We assessed the situation and let them take the boy. We can take care of Subhagi, but we cannot go and fight for the boy. In any case, he hates his mother. He holds her responsible for his father’s death, and his grandfather keeps filling his ears with lies,” say Subhagi’s brother as she continues to sob.

The group of NGO officers present turn away from her to confer among themselves. One says, “I know the police here, maybe I can speak to them to lean on the family a bit and allow Subhagi to have access to her child.”

Another field worker retorts: “Ha! Subhagi’s in-laws are police officers themselves. Did you know that? Be careful, we work in this area, we cannot afford enemies. If you meddle in their affairs, it’s an affront to their honour. The problem should have been tackled at the beginning when her mentally ill husband first started ranting and going to visit pirs and fakirs to identify the demon inside him — someone needed to redirect him to a psychiatrist. He needed to be sedated and treated. Instead of a psychiatrist, he got guidance from a man crazier than him.”

And so the matter rests, but it indicates how in Pakistan, mental health is not prioritised. The statistics are telling: according to the World Health Organisation (WHO), there is just one trained psychiatrist for 100,000 mentally ill people in the country.

Javed Iqbal and Huma Halepoto work with Basic Needs, an NGO that seeks to alleviate the suffering of impoverished people grappling with mental health issues.

They do this by setting up medical camps, but before they start, they have ‘social mobilisers’ or volunteers from the community go door-to-door in the area selected, advertising the services of the NGO, and explaining that those with apparent symptoms, like epilepsy for example, must come in to be diagnosed and treated. Halepoto and Iqbal are constantly coordinating community meetings and training sessions, awareness-raising events and medical camps. They take psychiatrists in to train doctors in rural Sindh in the hope of reducing the exploitation of mental health patients.

Recently, Basic Needs set up medical camps with psychiatrists in the most deprived areas of rural Sindh and three destitute areas of Karachi, providing the most vulnerable section of society, whom they call ‘beneficiaries’ or ‘clients,’ access to diagnosis, treatment and medication where appropriate.

Deep inside a slum nestled in the  heart of Korangi’s industrial area, Halepoto is running a community consultation session, galvanising volunteers to come forward and identify households where people are likely to have mental health issues that have not been addressed. Of the 200 people who attend the consultation — and are shown how to identify epilepsy, schizophrenia, severe depression and a whole host of other common disorders — about 40 sign up as volunteers. Many of these disclose they know of mentally ill people who are chained, naked, and mistreated by their own families. The NGO field workers immediately jot this information down in their registers.

Halepoto says, “We train volunteers to identify mental health disorders and train them to dispel stigma in the community. But we also say that anyone dealing with stress has to have a coping mechanism. And this is not a disease, or a curse; it is treatable, and the family must build a nurturing environment to heal the person who is suffering. We must accept that depression can happen to anyone.”

He continues, “We cannot go against the traditional treatments that people usually resort to in an almost ritualistic manner in cases of mental illness. But we say they should also come to the medical camps, and commit to trying the treatment prescribed by the psychiatrist there, and we work with the family to treat the person with the disorder with dignity. That is why we call them beneficiaries or clients. Change must start with us. We must give our patients the dignity of being called by a neutral name.”

According to Iqbal, “Right now quacks can misdiagnose or abuse a little girl and say they are taking the demon out of her; they can beat someone to pulp and take their life savings away because they have convinced the family that they are curing the sick individual of the evil inside. There are also a lot of good doctors working in the field, but they have no training, so we are working to fix that. We did a survey of 99 doctors in Matiari, and found only one had the training to diagnose mental health issues.”

After several interviews at the Cowasjee Jehangir Institute of Psychiatry in Hyderabad with a dynamic set of young doctors, it became clear that a lack of training isn’t the only problem.

“There is a stigma against going to a psychiatrist and there is a stigma against becoming a psychiatrist. I was toldpagal ho jaogay paglon main ja kar (you will go crazy among crazy people),” says one doctor. “There is a lot of stigma — for the doctors, for the patients, for the family. So everyone lives in denial. We are a schizophrenic society.”

A group of doctors nod in agreement. One of them says, “For a long time there was only one segment in the syllabus for a medical student interested in behavioral sciences, and only one optional question in the exam. What is the implication? That psychiatry just isn’t a field to focus on.”

The medical superintendent at the institute grimaces, saying: “We are considered freak-shows by the local media and students. There was a time when people even bought tickets to come here; of course that practice was banned. But I can show you the tickets, I still have them. We still chase away students on motorbikes; sometimes even schools want to take a field trip to gawk at our patients.”

The ward rounds at the institute are informative. In the midst of one, a doctor turns aside to debrief another colleague about a difficult case. The ‘case’ is that of a boy who appears to be drugged, and whose family admits to having taken him to pirs who have beaten him within an inch of his life. The doctor says, “Virtually every patient we get here has been to a pir for treatment. We cannot eliminate the faith healers, or prevent patients from seeking help there. What choice do they have? We don’t have enough doctors.”

Back in Karachi, at a Basic Needs medical camp in Ibrahim Hyderi, it is late in the day, and volunteers and patients are still pouring in. “This is a typical day for us — but with a twist. We were expecting 50 patients, and we have already seen more than 70,” a field officer reports. “I like it here,” says a female beneficiary shyly, as she concludes her session with the psychiatrist. “They make me smile; no one beats me or pushes me here. I used to feel lost and would start staring out into nothing. I would collapse with my arms and legs in strange positions; I used to have fits, but I’m getting better. I think I will start stitching soon, and I cook too.”

Her mother chimes in: “This is our fifth medical camp, and they don’t want any money. We tried so many treatments, but since she started here, she is better.”

The girl in question has epilepsy, and was being treated by a faith healer who had instructed her family to bring her in for a beating every time she collapsed in convulsions.

Another woman who was diagnosed with chronic depression explains how the volunteer who visits her lets her speak her mind, and lightens her heart. “I always had a heavy feeling in my heart and I thought I had a heart problem, but I learnt it’s because I was anxious. I am the sole earner in my family. Now I don’t take loans I cannot pay off. Basic Needs has self-help (apni madad aap) groups that I am a part of, and there you can talk to other women with similar problems. I tried to kill myself twice, but at one of the camps I met someone who had attempted suicide thrice. She is getting better, and so I believe I can too.”

As we drive four hours out of Karachi, past the scrubland into rural Sindh, we find a group of beneficiaries bent over lush green fields studded with fluffy white cotton-puffs. They tell us self-help groups in Matiari have rapidly moved into the realm of income generation, taking orders on straw products like bread baskets when they are not harvesting kapaas (cotton).

According to Samreen who works for the Sindh Graduates Association Mental Health Project: “Women in these areas recognise that earning an income is the only way to raise their status in their homes and communities. Many women who have mental health issues are often married off in the hope that it will be a cure. Some women are married to cousins who are mentally ill, because they are told the pir their family believes in prescribed the union, and they have no choice in the matter. Poverty, forced marriages, chronic depression… a common cycle.  When we start treating these women and see them recovering, we get them into apni madad aap groups so they don’t relapse; so that they have something to look forward to. It’s just a few hours of training and it costs nothing.”

Over a few weeks of working with female patients, rumours abound about faith healers who exploit women sexually. An investigation is launched into the prevalence of the practice. At first the questions asked are met with confusion. The women wade through the dilemma of allowing strangers into their sad, seamy, lives. Then slowly, they begin to share their stories, initially among themselves, and then with us.

A gaunt-looking woman in frayed purple cotton says, “There is a man whom many women go to see, and we have a joke about him. He says, ‘here, hold this,’ and you find yourself holding a cucumber. He tells you, ‘just hold everything I give you tight and rub it.’ And then he says ‘hold this, it’s an orange.’ Eventually he hands you his penis, and asks you to rub that. He promises barren women if they do it they will have a child. He tells others they will be rid of the evil spirit that hovers over them. Desperate as they are, many women agree.”

There are allegations against another so-called healer. We enter a tangle of slum dwellings, and as we go deeper into this urban maze in the midst of Matiari, the houses become taller, better-built, and the streets more spacious.

“Surprised?” our local guide asks us, eyebrow arched. “Don’t be. We have some strange people here who earn in strange ways.”

She takes us to the house of a man renowned, she tells us, for treating childless women by putting two fingers in their vagina and reading a few sacred verses.

“My friend who came here is an educated woman, a lady health worker. She is still traumatised by the feel of his fingers inside her, but please don’t judge her, she is bay-aulaad (childless) and under a lot of pressure from her in-laws to produce a child,” she informs us.

We enter a dark room where a man in a white pyjama-kurta is lying in a darkened room. “His relatives say he had his eyes gouged out by the Saudi police for his role in trafficking women from Sindh (we later speak to a law-enforcement officer who confirms this),” says health worker Samreen. The man rises and walks us through a set of high ceilinged rooms, two of which have sleek air conditioners and flat screen TVs, to a living room.

When we ask him about his eyes he leans in close and says, “Don’t be afraid child, give me your hand, and I will tell you how my pet demons took my eyes from me as I was treating a girl like you.” We ask if we can meet his ‘pet demons’ and he replies, “They are with us now. Don’t upset them as I cannot always control them.”

Then he begins to shriek, jerking back and forth, allowing his shoulder-length grey and white curls to cover his face. We ask how he stumbled upon the dark arts, and he tells us he learnt the craft in Indonesia from an Indonesian woman he picked up during a Hajj pilgrimage. We film his answers and ask to leave.

He begins to speak urgently in Sindhi to his daughter.

Halepoto smiles furtively and whispers: “He is asking whether we will bring the police here…”

Gazing across fields laden with bananas bursting with sweet promise, our team stands silent, deflated. We turn our back on a village where we failed to convince a family to unchain their daughter, and try to cope with our sense of frustration. On our seventh mission in the field we are beginning to grasp the breadth and scope of Pakistan’s mental health problem.

An imam had led us to Saleha, and her family warned us that she was violent. She sat huddled on a metal bed, a metal chain circling her bony ankle, a half-eaten banana by her side. She twiddled her fingers incessantly in circular motions, her face twitching. A deafening silence met with our requests to bring her into medical camps for diagnosis. Her family claimed she was aggressive, but when we eased the chain off her foot, she could barely muster the strength to take a few steps. Her youngest sister confided that Saleha was “normal” till she was 10 years old, but one evening, when their father returned from the mosque, fresh from a sermon about the evil embedded in television programming, he saw Saleha watching TV. She ignored the rant that ensued and “when she refused to turn off the soap opera, he dragged her off the charpai, and wouldn’t stop kicking her everywhere, including the head.”

We sit inside an office in Hala, a fan struggling to provide relief from the relentless heat, sipping sweet, milky tea. There are files stacked high to the ceiling that a clinical psychologist and pharmacist are preparing to delve through in preparation for the next medical camp. They work in silence. The whole office appears to be distraught by the news of a tragic death in a neighbouring village.

“This young girl was treated by a healer, and after a night of screams, the family opened the door to find her dead,” says Dr. Zia, who has decades of experience in fighting ignorance while he offers medical care. “Her spine had snapped; the healer claimed it was a demon that ‘broke’ her. I went to her house, but her family members wouldn’t speak, I imagine out of shame. I think they realise the young girl had been sexually abused. This child was tortured because her family didn’t have the awareness to understand her situation and placed her in the hands of a dangerous quack.”

Dr. Zia blinks frequently, wringing his hands as he talks. He says he should have been able to prevent the torture and death of the teen who had died in his neighbourhood.

He continues, “I gave the story to a local journalist, but he took a bribe from the healer to bury the issue, so there will be no justice.”

Samreen, who has a masters in Sociology and seven years of experience in rural Sindh, says: “No one wants to admit that a family member has mental health issues. They are afraid people will say, tumhari family may sub pagal hain. They would rather claim a ghost has possessed their family member because then they can hand the problem over to a healer. We must get the healers on board, like we are sensitising religious leaders.”

Dillip, who works to bring religious leaders into the fold of his NGO’s awareness-raising campaign, says, “I was turned out of a few mosques, but some mosques allowed me to make announcements from the pulpit, and and so my voice was broadcast across several villages. The Hindu villagers couldn’t believe a Hindu like me had been let into the mosque. At first, the imams said to us, ‘we have no mental problems, our faith is strong.’ The truth is, mental illness is a source of income for them.”

Dr. Ghulam Shabir Sheikh, a psychiatrist at the CJ Institute of Psychiatry explains: “A lot of girls have fits not only because of epilepsy, it could also be conversion disorder. Women in rural set-ups cannot express their feelings; they fear saying, ‘I am sad.’ So they will hold in the trauma or sadness. That sadness will then manifest in another way — in physical symptoms. Then they will be taken to a shrine where the healers will offer to remove the demon inside them for a price. For the women, this is their rare chance to get out of the house; it is a way for them to work off their frustrations.”

Dr. Sheikh explains that in rural Sindh, where there is no place for men and women to interact openly, the shrines offer a subversive sense of freedom under the guise of submitting to the will of a saint. “There is music and prayer, and hordes of people. It’s a mela, and there are sweets and a sense of purpose. And then, there is the added attraction of women who begin to sway and toss their hair and bodies around at the bidding of a fakir who channels the ‘demons’ within them and forbids them from entering any holy space.”

Dr. Iqbal Afridi, head of psychiatry at the Jinnah Postgraduate Medical Centre, explains, “Imagine if a woman trapped in a strict household has a fit and is taken to a shrine. It is full of colours and lights, there will be music and dhamaal, the priest and the family will encourage her to move, to sway, to ‘let the demon out.’ The female is allowed to express her pent-up feelings. So the process of the dhamaal, the dancing, is a catharsis. In our country, accusations of ‘witches’ or ‘bhoot’ (ghosts) or ‘demons’ are normal — but we can only fight ignorance with the awareness of mental health disorders. The problem is we don’t have data, we don’t know the prevalence of mental health issues in this country, so where do we start? Perhaps with more research projects and by training the right number of psychiatrists, shrines will no longer be seen as the only solution.”

Professor Afridi has been in the forefront of bringing change to the profession of psychiatry by lobbying hard for the inclusion of behavioral sciences in the first and second year of medical college, and persuading doctors to accept that a basic understanding of a patients’ psychology is essential to all faculties of medical science.

Back in rural Matiari, on our umpteenth mission into the field, we sit cross-legged in the verdant embrace of a flourishing garden that borders an intricately carved shrine. The volunteers are perturbed by their elders’ stubborn attitudes.

Ten of Basharat’s cousins, all fathered by his mamoo (maternal uncle), have epilepsy. He says, “We now have the training to know this is not a coincidence or a demon curse. He married his cousin, like his father before him, so the blood has problems. But the healer says, ‘it’s not your fault, it’s not your blood, it’s the demons.’ So we need two solutions: we need to stop the healers from spreading these lies, and we need experts to come and educate our elders.”

Safdar, 27, Ali Hassan, 34, and Basharat, 30, are all single and suffer from epilepsy. They have all had their marriages arranged for them with their cousins from the village of Syed Khan Leghari.

Basharat adds, “By this consanguinity, we are being condemned to creating more mental health problems. If we resist, that can ignite a war or blood feud between the families. We want to bring inquilaab (revolution) to our communities and reject such unions. We beg you, bring doctors here, explain that we have to stop marriages between cousins. Look at Imran…”

Imran Bekul Rana would fly into fits of rage, breaking anything he found, intimidating family members, and frightening neighbours. He discloses, “At a complete loss, I went and sat at the shrine and it was right around the time of the brutal slaying of the four children of that widow Subhagi. My wife thought I was going to kill her in imitation of that crime.”

But as Imran sat at the shrine and watched the healers operate over four days, extorting as little as 30 rupees from desperate families to tie useless threads around necks and foreheads, and Rs. 100 to drink water out of a bowl that had been ‘blessed,’ he began to realise there must be another way. “I found the music calming, and there was always food to be distributed among the poor, and there were always people in worse situations than mine, so it made me feel better. But I didn’t see any cures. Still, I am attracted to the idea of the shrines, there is a feeling that magic can happen. I sympathise with Subhagi’s husband. I want to be powerful too, and the men who run the shrines do look powerful, but then why do they beg us for Rs. 30 for thread?” he asks.

That question hangs silently over us as we make our way back to Karachi. We know the answer. A complex system of deception allows these ‘holy’ men to weave spells over the poor, drain them of their meagre earnings, and leave their mental state worse than when they came in. The arrogance of these faith healers is reinforced by the fact that they need not fear being reined in by law-enforcers. A few thousand rupee notes slipped into the furtive palms of policemen will make any charges of sexual misconduct, or physical abuse disappear. Meanwhile, cousins will keep inter-marrying and destabilising society by exponentially increasing the risk of producing children with mental health disorders.

The government must join hands with civil society to mount a strong, multi-pronged campaign to collect data about the prevalence of these disorders, to educate the rural and urban poor about the consequences of inter-marraiges, to banish the stigma that sticks to the most vulnerable members of our society, and to train doctors to identify and treat those who suffer from mental health issues.

The point is, in a country in the grip of so many problems, does anyone care? If only to salvage our own dignity and retain the right to call ourselves a civilised society, we must start doing so.

This article was originally published in Newsline’s December 2015 issue.