YESTERDAY, Sept 10, marked another World Suicide Prevention

Day. Suicide is a global public health challenge, the prevention of

which was declared as ‘imperative’ by the World Health
Organisation in 2014. This is because most suicides are
preventable.

A country with a strong doctrine of save-a-life-to-save-humanity, Pakistan

signed up to reduce suicide mortality by 10 per cent by 2020 as part of the
Comprehensive Mental Health Action Plan 2013-2020. While many countries
either initiated or strengthened national suicide prevention programmes in
response to this, Pakistan failed to do so. Now, Pakistan has prioritised a set of
global goals under the SDG 2030 agenda, including pledges to reduce
premature mortality from non-communicable diseases by one-third through
prevention and treatment, and promotion of mental health and well-being. To
achieve this target, the designated indicator to be monitored is the suicide
mortality rate. There is an excellent opportunity here for the government to
develop a national suicide prevention plan.

Eight years ago, the WHO estimated there were 13,377 suicides a year in
Pakistan — 7,085 women and 6,021 men. The rate of attempted self-harm is at
least 20 times higher, contributing to a significant burden of suicidal
behaviour (a term that includes completed suicides, attempts of self-harm and
suicidal ideation). Though outdated and under-reported, this burden is still
alarming. From some studies in Pakistan, we also know that suicide and
attempted self-harm are more common among the young, ie under 30 years of
age. We also know rates of suicidal behaviour are higher in Pakistani women
than men. Other known risk factors include mental disorders, lower
socioeconomic status and domestic violence. Multiple clinical, psychological
and sociological variables contribute to suicide psychopathology, all
necessitating an urgent and comprehensive national suicide prevention
programme.

Based on our resources, collaborative evidence-based strategies, aimed at both

the individual and population level, and across multiple settings, should be
considered. These may include suicide-awareness campaigns, gatekeeper
trainings, access to mental health services, restriction of access to means,
media strategies, etc. But this can only be planned if Pakistan first has an
effective mental healthcare system in place. Isolated strategies like
establishing suicide helplines are likely to waste resources and have limited
impact if these are not supported by, for example, credible referral pathways
to specialist services.
There are two reasons why Pakistan lags behind when it
comes to prioritising mental health.
Principally, there are two reasons why Pakistan continues to lag behind when
it comes to prioritising mental health. The first are the capacity constraints
within an under-resourced health sector that is, for the most part,
overwhelmed by public health challenges, including maternal mortality,
malnutrition and infectious diseases. Because we think of mental health as a
subsidiary of health in general, it continues to remain low on the list of
national health priorities. A lack of any implementation of mental health
legislation in the country in the last two decades is a glaring example that our
national mental health agenda remains destitute.

The second is the demand that any serious effort to address mental health will
make on inter-sectoral collaboration with the ministries of health, human
rights, education, interior, law and justice, and disaster management
authorities. Tackling mental ill health simultaneously requires the government
to holistically address the burden of mental disorders; confront an ever-
growing challenge of substance abuse; deter psychosocial adversity including
childhood abuse; institute stress-coping mechanisms in young people; prevent
gender-based violence; and provide psychosocial support in response to
conflict-affected populations or following humanitarian crises. This means
that policies that are developed in silos will always fall short.

Until serious efforts are undertaken to prioritise mental health and formulate
a comprehensive national suicide prevention programme, there are at least
three interventions that Pakistan still ought to initiate to monitor the relevant
SDG indicator.

First, Pakistan must decriminalise attempted self-harm. This is vital because

Section 325 of the Pakistan Penal Code is a strong deterrent for most people
against seeking medical help, and problematic because detection and
treatment of high-risk cases is a critical suicide prevention strategy. Previous
attempt of self-harm is a well-known risk factor for completed suicide. A bill to
amend Section 325 was passed by the Senate in 2018 after approval by the
Council of Islamic Ideology and sent to the National Assembly, but
unfortunately lapsed following the change in government.

Secondly, Pakistan must set up a national suicide register. The WHO regularly
collects suicide data from all member states. Pakistan submits low-quality
data on suicides as it is not part of the vital registration system and we do not
have official mortality statistics. The complete recording of suicide deaths in
death-registration systems requires good linkages with coronial and police
systems, yet this is seriously impeded by stigma as well as other social and
legal barriers. The provinces will thus have to set up effective surveillance
systems to contribute to the national suicide register.

Third, Pakistan must regulate the sale of pesticides and firearms. The three
most common methods for suicide in Pakistan are hanging, ingestion of
commonly available pesticides, and the use of firearms. Pesticides are highly
toxic, commonly used in agriculture and widely available across the country.
Similarly, of the 20 million firearms used in the country, only 7m happen to be
registered. There is scientific evidence to suggest that restricting access to
means of suicide leads to a significant reduction in suicide mortality.

While much work needs to be done, there is an encouraging development as

the Ministry of Planning, Development and Special Initiatives is now looking
to implement a Mental Health and Psychosocial Support initiative as part of
its Covid-19 emergency response, to be piloted in the federal capital. This
project aims to develop a scalable model based on e-mental health
interventions, build the capacity of a mental healthcare force through a task-
shifting approach, and provide mental healthcare at multiple levels. If
successful, this model may offer an effective framework to address mental
health at a national level, possibly in tandem with a robust suicide prevention
programme as a first step to tackling what is essentially a major public health
challenge.

The writer is a consultant psychiatrist.

Twitter: @AsmaHumayun

Published in Dawn, September 11th, 2020

IT has been only two years. We are still getting to know each other.
Hence when sometimes it is not immediately clear what the
government means by a certain measure it takes, there’s no reason
for anyone on this side to be overly alarmed, so long as we keep in
mind that almost all approaches on the land are based on cashing
in on the same old conservative sentiment — even approaches that
have to do with mediums that we were once told thrived on
progressive visions. Mediums such as television.

Earlier, it was thought that this was a strict disciplinarian set-up that brooked
no diversion. Like everyone else in the business, it sought to combine all the
good qualities gifted by religion, an anti-West ideology and this and that
foreign and ultra-patriotism to create a proud prototype for the crores in this
country to emulate in letter and spirit. But then, there have been episodes
where the supposedly rabid system does give some leeway to first-time
offenders. Such bumps will surely be smoothened once we know each other
better, this term or a few terms from now.

The vigilant Pakistan Electronic Media Regulatory Authority has just delivered
on its promise. It has asked television channels to refrain from airing two
drama series. Both the plays recently ran to crowded TV rooms apparently.

Now it has been decided that an entertainment committee will be formed to

decide what is kosher for television audiences in the country. This means we
could be in for some real fun and some more actors in the renaissance-bound
Turkey will soon be ordering Pakistan-specific dresses as proof of the purity of
their art. What is a bonus is that the designs of the greedy profit-makers
looking to make easy money by going for a re-telecast so soon after the
original runs will stand defeated.

Pemra itself cannot be faulted for jumping into the pool

without first telling everyone to cover up.
A ban was expected at anytime even if the reruns, whatever their commercial
merits or demerits, were supposed to be a safer bet than your fresh first-time
releases. That impression about getting away with second unrevised editions
of the old, however, must have suffered a dent after the Urdu translation of an
old book on mangoes didn’t go down too well with certain authorities.

Pemra itself cannot be faulted for jumping into the pool without first telling
everyone to cover up. Two years ago, it had warned the television ‘content’
producers to behave or get ready to receive advice on what it deemed fit for
Pakistani consumption. And before anyone blames the PTI, which is only into
its first run, Pemra in 2018 was only echoing Pemra in 2017 or what the
authority had been saying even earlier.

I happened to watch a few instalments of Pyaar kay Sadqay, albeit with the
guilt of all those loath to be found in the company of ‘digest’ writers
masquerading as playwrights. But to tell you the truth my wayward eye could
discover little of the sort that could prevent a repeat of the serial on screens.

The play had its frustrating moments for someone essentially looking for
entertainment, an escape from the death, disease and debt piling up all around
in the wake of Covid-19. The colours could be too in your face and it is
perplexing still what the director wanted to do by foisting his heroine on that
machan or the hunter’s ambush post for long periods of time.

To tell you the truth, a certain Umair Rana in the role of an evil stepfather out
to steal his stepson’s wife would have been easier to watch if one had been on
assignment to write on the play. Thanks to Pemra, the ignominy of having
watched a mainstream Pakistani TV drama — quite suggestively often
pronounced to rhyme with ‘trauma’ — has been avoided. Pyaar kay Sadqay has
eventually proved to be worth writing a few paragraphs on.

The play did leave an impression even if it seemed as if it was rather hastily
wrapped up. As a non-progressive, art for art’s sake, non-reviewing viewer
allergic to tear-jerkers, I could sometimes barely bring myself to watch Umair
Rana’s antics, especially towards the end, when perhaps in an effort to wind
up fast, the story turns rather blunt-edged and a bit too filmi. The actor did
draw a negative reaction, which is a tribute to his skills. Just like that, Yumna
Zaidi in the role of his vulnerable prey rekindlee memories of a whole
generation of yore. They must still be making them like this to inspire the
writers.

I presume it is the conflict between these two characters that has forced the
sensitive souls sitting on the Pemra board to raise objections about a second
screening of the series. You may want to call it conflict or relationship or
exchange or whatever. The first time can be put down to the innocence of the
director and writer who had the raw imagination to paste that truly theatrical
beard on Munshi Sahib and who had the vision to cast Atiqa Odho in a role
where, among other assigned responsibilities, one of her duties was to look
aloof. But the second time, it is a sin.

We are in safe hands. When we learn of such steps by Pemra, and when we
read in the newspapers that the Pakistan Telecommmunication Authority has
put a ban on certain apps used for dating to curb unwanted trends in society,
we know we are safe, as safe as we were, say, back in the 1980s. We are safe
from exposure to obscenity and vulgarity, and I don’t know whether you are
one of us here, because we don’t know how to beat this system of bans when
there is so much for a thinking mind to choose from. Those who know are
aware that they can easily frustrate these noble plans to preserve their
innocence with a few clicks of their empowering gadgets.

 MAJOR flaw in the system exposed in the recent heavy monsoon

rains in Karachi was that over a period of several decades, due to
criminal neglect on the part of the authorities, sewage is disposed
of in storm-water drains by both unofficial katchi abadis and
formal sector schemes with official sanction. These drains have
also been blocked by encroachments. All this resulted in the
flooding and overflowing of sewage all over the place.

What Karachi needs immediately is a technical assessment of the urban

flooding disaster carried out by experts, along with democratic consultation
with the public and local stakeholders, before any drainage improvement and
sewage disposal schemes are proposed. The objective should be to make this a
part of proper town planning in order to create a master plan for Karachi.
Otherwise, making a plan without coordination with the various stakeholders
and departments would be tantamount to pouring more concrete and steel
into the already heavily built-up metropolis, resulting in worse urban flooding
in the future.

Briefly, the immediate need is: (i) The appointment of a panel of experts as a
planning body; (ii) public consultations (conducted with the help of the
panel); (iii) a city master plan and project designs based on research/technical
assessment of urban flooding impacts and stakeholder consultations. Not
following these guidelines would be like saying we can make a building more
quickly if we skip laying the foundations.

The master plan should be implemented by one empowered municipal

government, which is responsible for the planning and problems of all of
Karachi and overlooks all areas, including the cantonments. This will do away
with the confusion of having multiple and uncoordinated authorities. This was
also agreed to in the Master Plan 2020 prepared for Karachi, but which was
never implemented.

The city needs a technical assessment of urban flooding.

Any master planning done for the city must take sustainability, with its core
concerns for environment, social equity and economics, as well as climate
change mitigation and adaptation, into account. This enables focus on aspects
such as a zero-carbon economy, energy efficiency, water efficiency, rainwater
harvesting, storm-water storage and groundwater recharge. Sustainable public
transportation and green architecture and industry become essentials.
Building by-laws would then also be revised keeping sustainability and climate
change adaptation in mind.

Karachi has suffered from many extreme weather events — heatwaves,

drought, urban flooding — which are expected to get worse with time — along
with sea-level rise already being witnessed in the Indus Delta. This metropolis
also serves as the hub for Pakistan’s climate refugees from other regions.
Pakistan is a signatory to the UN Agenda 2030 (Sustainable Development
Goals, or SDGs), and the Paris Climate Agreement, which are designed to
address what our country is going through. The Pakistan Environment
Protection Act, 1997, requires public consultations on large project planning.
The national and provincial climate change action plans also commit to this
way of thinking.

The Pakistan National Climate Change Policy, 2012, identifies both disaster
preparedness and well-coordinated town planning as major areas for
preparation for climate change (with Karachi and Lahore mentioned by name
as the largest cities needing urgent and extensive planning) that can bring all
challenges, including those of water and energy, together effectively.

This planning before development work would need to be paired with the
revision of the city’s building by-laws which would incorporate the revised
drainage and sewage guidelines as well as what are referred to as ‘green
building norms’ around the world (including our neighbouring countries
which are just as poor). These norms address the environmental crisis and
climate change adaptation agenda. At the moment, our buildings are
unbearable with regard to heatwaves and other extreme weather events and
are highly energy inefficient, further wasting our dwindling water and energy
resources.

It is high time that we brought the discourse on SDGs and climate change
adaptation into our local and national planning, as we have been promised by
the highest quarters. Or are we, as technocrats and educated citizens, expected
to believe that all these conventions we signed onto through our elected heads
of state and the laws that were passed by our elected representatives, as well as
all standard planning and building practices that we were taught as being
essential from an ethical, legal, engineering, health and safety point of view,
are only meant to look good on paper but are actually a farce? Can they be
thrown out of the window whenever some lower, more selfish gains come to
tempt us?