Hanging by a thread

KARACHI:

Soon after she was married, R* discovered the demons her husband often struggled with. Not only would he take out his anger and frustration on the people around him, he would sometimes target small animals as well. Still, R never dreamed her husband’s final victim would be his own self.

R had planned to leave for her hometown of Kohat to look after her then seriously ill mother in the days leading to her husband’s suicide. Right as she departed, her husband, who sometimes showed a tender side too, handed her a lunch box lovingly. “It’s a long way… don’t starve yourself,” she recalls her husband saying. She had no inkling those would be the last words she heard from him.

“When I reached Kohat with my sister, we received the news the same day. My husband had killed himself,” R said. “I had left three teenage kids at home. They told me their father was dejected when I left. They told me he said I didn’t listen to his pleas to stay.”

According to R, on the best of days her husband would tell her how lucky he was to be with her. “But when he was ill, he would torture us… me, my kids and everyone else at home. He even ended up killing the cats in our neighbourhood,” she shared.

R’s marriage took place nearly two decades ago. Only 16 at the time, she tied the knot with a distant relative living in Karachi. Now 40-something, the resident of Karachi’s Labour Colony says neither she nor her parents had any inkling of her husband’s mental health issues.

“His family hid his condition from my parents when our marriage was arranged,” R said. “But a few days into our marriage, it dawned on us all how severely troubled he was.”

One of the first troubling episodes R experienced took place after a stray cat intruded their home just a few days after the wedding. “It bothered him quite a bit. The next day I woke up and saw the dead cat hanging from a gas pipe near the kitchen,” she recalled.

“It shocked me to the core and I was speechless,” R said. “I was so young back then, and it took me years to understand that he had serious mental health issues. My in-laws used to take him to spiritual healers for treatment but that only made his condition worse.”

Creative: Ibrahim Yahya

R’s husband worked at a towel factory where he would hurl chairs and tables at other workers. When his condition grew worse and he was no longer able to work, R also began working at a factory to make ends meet. Her story, however, is no different from that of many other women in the country who have no choice but to spend their entire lives with mentally ill spouses, whose illnesses go untreated because of lack of awareness, poverty and many other such factors.

An epidemic in the making

According to a recently published report by the Sindh Mental Health Authority (SMHA) titled ‘A study of registered cases of suicide in Sindh between 2016 and 2020’, a total of 767 cases of suicide were registered in Sindh during the last five years. In a gender-wise classification of suicide cases, 462 men and 301 women took their lives across the province.

The data included only those suicide cases that were registered at the district health office and the police department. It revealed that Tharparkar district had the highest number of suicides with 79 reported cases. It had the highest number of women suicides with 48 more women taking their lives and 31 men taking theirs. The report also revealed that Tharparkar, Badin, Dadu, Mirpur Khas, Sanghar and Umerkot had the highest rate of suicides.

In the other districts, out of the total 70 cases of suicides reported, the number of women is 36 - slightly higher than the number of 34 cases of suicides reported of men. Similarly, the number of suicide cases in other districts during the period were: Badin (77), Dadu (73), Sanghar (66), Umerkot (64) were found to have the highest number of cases followed by Tando Allahyar (40), Tando Mohammad Khan (33), Naushahro Feroze (31), Hyderabad (28), Malir (24), Shikarpur (23), Karachi West (19), Shaheed Benazirabad (18) and Sujawal (18). Furthermore, Jamshoro had (14), Thatta (13), Karachi East (12), Karachi South (12), Ghotki (12) Matiari (10), Karachi Central (8), Jacobabad (7), Qambar-Shahdadkot, (5), Khairpur, (4), Larkana (3), Sukkur (3) and Kashmore (1).

 

According to the 2018 Human Rights Commission report, in Pakistan, various reasons such as lack of necessities of life, lack of peace and political instability, unemployment, health issues, poverty, homelessness, family disputes and a range of social pressures are causes for mental illnesses.

Psychiatrist and Assistant Professor of Psychiatry at the Liaquat Medical University of Health Sciences (LMUHS), Hyderabad and author of the report, Dr Jamil Jonejo tells The Express Tribune that because of the rising number of suicide cases in Sindh and especially in Tharparkar, we came up with the idea to compile a report. “The aim was to bring the government’s attention towards mental health illnesses being faced by the people and also to promote a suicide prevention programme,” he explained. Dr Jonejo also says there is an acute shortage of psychiatrists and psychiatric facilities in the province.

When Pakistan was created, there was Lunacy Act by the British for the purpose of regulating mental health laws. While India repealed it in the early 1980s and suggested some reforms, in Pakistan, unfortunately no sufficient work was done. Before the 18th Amendment, mental health was the federal government’s subject and during Parvez Musharraf’s era, the Mental Health Ordinance 2021 was introduced.

In 2013, Sindh Mental Health Act was introduced and Sindh Mental Health Authority (SMHA) was established in 2017 and in all provinces, Sindh took the lead in addressing the problems of mental health but has faced financial constraints since then. “We ensured people who made blasphemous remarks and committed suicide must fall under the Mental Health Act. Under Pakistani law, suicide is still a criminal act that needs to be decriminalised,” he emphasised. “The Sindh Mental Health Act 2013 has documented suicide as an illness and cry for help rather than a crime.”

Dr Jonejo said that for the report, the research team didn’t include attempt-to-suicide cases as those were not registered.

“The reason of under-reporting of suicide is that it is considered a criminal offence under the Pakistan Penal Code with punitive laws imposed for attempted suicide punishable by a fine of Rs10,000 and/or imprisonment,” says the meritorious professor and former chairman of the Psychiatry Department at the Dow University, Dr Raza ur Rahman.

Official constraints

Sharing details of the report, Dr Jonejo says SMHA members often discussed that there was a need to carry out a proper study to record the number of suicides, but it wasn’t happening because of the paucity of funds. Later, the authority launched this report of registered cases only as it didn’t require huge funding. Two years ago, the Sindh government granted only Rs200,000 to SMHA for the pilot project, so the authority members had a meeting and spent the funding on the report of registered cases instead of spending the amount on the pilot project, says Dr Jonejo. Therefore, the authority involved health centres and the police department. “We figured out mostly police declares death cases as suicides, but we also involved health centres. We found police data reliable because health department was also reporting to the police department.”

Dr Jonejo says they had various limitations but SMHA Chairman Dr Karim Ahmed Khuwaja wanted them to publish data of registered cases at least, and they did successfully.

An epicenter in Tharparkar

According to SMHA report, 49.8% of suicide cases were registered in Tharparkar district in 2020.

However, Pakistan Peoples Party’s (PPP) Tharparkar District President, Samtra Manjiani tells The Express Tribune that 80 per cent of the suicide cases in Tharparkar are actually murders. “Both the police and doctors are involved in the crime,” she claims. “Also, parents also issue statements saying that their children committed suicide because of cognitive disorder or depression but that is not the case most times,” she says, adding that soon as she learns about a suicide case, she reaches the spot and look for evidence herself and in most cases, she comes to learn that it is actually a murder case.

She shares one such recent incident that took place on January 01, 2021, in which bodies of a married man and his sister-in-law were found hanging from a ceiling fan in a house owned by ASI Gul Muhammad Sand in Fakeer locality of Mithi, Tharparkar.

The neighbours had cast doubt on the suicide of 39-year-old Doongar Meghwar and his sister-in-law, 20-year-old Babita Meghwar. “Doongar worked for an NGO and was friends with ASI Sand but they had developed some differences over some matters, thus, Sand hatched a plot to have him killed. In order to present the double murder as suicides, ASI Sand invited Meghwar’s sister-in-law to his house for some urgent work and had them killed and told people that they had an affair and that’s why they took their lives,” she says, adding that the neighbours informed media that it is unlikely that Doongar, who was the father of four and was married to Babita’s elder sister, would choose to take his own life.

Manjiani shared that just as the news of the double murders broke out, she visited the place and found their bodies hanging from the ceiling fans. “I also doubted they committed suicide because the house looked like a brothel. I collected various things such as creams and condoms etc from there,” she said. “The police had already declared it a suicide, saying Doongar and Babita had a love affair and wanted to get married.”

Manjiani says she insisted there is a need to carry out a proper investigation but they did not listen to her. “Six days after the murders, the victims’ families and I staged a sit-in outside the Mithi police station. Later, the police were forced to register an FIR and took the bodies for a postmortem. The postmortem reports showed the victims were beaten up and their ribs were broken. So, my suspicions of murder were true. ASI Sand was running a brothel and was arrested later,” she shared.

Doongar Meghwar’s cousin Mendhro Valasai, who is now looking after the case and works at Jinnah Hospital as an MRI technologist in Karachi, told The Express Tribune that a new investigation officer was appointed to deal with the case but despite the passage of three months no further development had taken place in the investigation.

Dr Jonejo, on the otherhand, refutes Manjiani’s claim and says that he cannot believe that 80 per cent of the suicides in Tharparkar are murders. “I am running a clinic in district Badin and have also been running a Sunday clinic for the last 13 years where almost 50 per cent of the patients come from Tharparkar district. Many of them have clinical depression and bipolar disorder,” he said. “80 per cent of the people who take their lives have serious mental disorders.”

Dr Jonejo says Meghwar’s murder was a high-profile case as ASI Sand was involved in the case. “It was a criminal act and the family should be provided justice,” he says, adding that there is no denying the fact that murders are presented as suicides many times. “Take the example of Dr Maha Shah’s case,” he points out and says they didn’t include her case in the report because the police did not verify it.

“When police shares their data with us, we had to trust them otherwise things could go against them. At this stage, we cannot afford to have any kind of confrontation with anyone. There is a need to talk about the problems of mental health without indulging in any kind of confrontation,” says Dr Jonejo.

It is believed that poverty is a major reason behind the high suicide rate in Tharparkar however, Manjiani refutes this claim. “I was born and brought up in Tharparkar. Back in the day, I have seen many families that spent days without food but they didn’t commit suicide so how come these days people are taking their lives while they are not as impoverished as people were before. I believe people are financially much better than their families in the past,” she says, adding that there are many social ills behind these murders.

“Most of the murder cases take place in Hindu communities in Tharparkar district. The communities in which most cases occur are Kohli, Meghwar, Bheel and then Muslim community,” she claims.

Downward spiral

Dr Rahman tells The Express Tribune that when a mentally ill person develops extremes of pessimism and feels helplessness, then he or she begins to get suicidal thoughts. If the condition remains untreated, the persons ends up taking his or her life.

The number of women committing suicide not only just in Pakistan but also across the world, is higher than men. According to Dr Rahman, in most cases, women are more willing to admit to depressive symptoms than men. Moreover, most depressed men resort to abusing alcohol and drugs, and thus are diagnosed as alcoholics or drug addicts rather than depressed.

Dr Jonejo however states that depression is more prevalent in women than men but that the number of men die by suicide is higher than women. He adds that more women attempt suicides but most men die because their selection method to kill themselves is usually lethal, for instance, they shoot themselves to death, hang themselves or jump into a river or sea while most women gulp down five or more sleeping pills if they want to die.

He points out that family social bonding has been damaged in the society due to huge urbanisation. People who migrated from villages to small towns due to unemployment and basic facilities later on face depression due to feelings of isolation.

Prevention and treatment

Dr Rahman explains that psycho-social intervention includes effective management of mental, physical and substance use disorders, easy accessibility of different clinical interventions and support for those seeking help, restricted access to lethal methods of suicide, availability of family and community support, learning skills for problem solving, can save many lives in the country.

“There is a need to have legislation on suicide prevention, otherwise we won’t be able to pursue this issue successfully,” says Dr Jonejo. He adds apart from Giddu Hospital in Hyderabad, there is no big psychiatric facility in Pakistan. There are no psychiatrists in 17 districts in Sindh province, therefore, the government needs to take an initiative.

According to Student Wellness Counselor at Ghulam Ishaq Khan Institute of Engineering Sciences and Technology, Swabi, Sumira Siddique, there is a need to create awareness among the masses about the importance of a healthy lifestyle. “The chances of clinical depression reduce if we sleep well, eat well and exercise regularly. Also, youths should be encouraged to share their thoughts and feelings with their loved ones instead of dying in silence,” she suggests. She adds if personality build-up, history, sexual abuse and environment causes someone depression, then there is a need to seek professional help.

Timely therapy

Sumira says therapy definitely helps because depressed people want themselves to be heard. There is a need to listen to their grievances and understand the cognitive behaviour that they have developed over time. Cognitive Behaviour Therapy (CBT) and Rational Emotive Behaviour (RBT) are wonderful tools to break the faulty or irrational thinking patterns but family should also be involved, she says and adds, depressed people should be provided with a conducive environment in order for them to feel better.

Siddique was of the view that these days most youths spend their time on social media and don’t involve themselves in healthy activities. “Routine life can also cause sadness so there is a need to add some fun to it. For instance, plan a day out, go to a party, meet a friend, cook a dish etc. Adopt some healthy activities and refresh yourself,” she advises.

In May 2020, the Sindh Mental Health Authority also launched a mental health helpline for psychological counselling during the Covid-19 pandemic.

*Names have been changed to protect identity.