The challenges faced by communities scattered across the valleys of Gilgit-Baltistan seem to be as daunting as the mountains among which they live. From education, to economic opportunities, to health and more, they struggle in terms of access and quality. The non-governmental development sector has been quite active in the region while the government also tries to fulfill its duties, albeit with excruciating slowness. One overwhelming challenge facing both state and society right now is that of mental health and suicide.
Being a woman usually exacerbates one’s disadvantages of poverty, mental illness and economic dispossession. A double suicide, of mother and daughter, which occurred last year in a distant part of Ghizer district, threw into greater relief the severe impact of natural disasters on mental health. The family of the deceased had lost their home in a glacial lake outburst flood. They were living in a shelter overlooking the lake that had submerged their home. Displacement, domestic discord, poverty and possible substance abuse were shared by the community members as contributing factors to the tragic deaths.
Dr Farzana Niat Jan is a consultant psychiatrist, and a native of Ghizer district. One of the only three psychiatrists serving in all of GB, she is currently practicing in the district headquarters of Gahkuch. She has diagnosed depression, anxiety disorders, pathological grief, obsessive compulsive disorder, adjustment disorder, psychiatric disorders related to pregnancy, and post partum depression in her patients. “The biggest challenge for me is that people don’t accept that they may be suffering from psychiatric illness. They prefer dam dua (prayers) and faith healers to seeking help from medical specialists. They subsequently suffer a lot before reaching proper treatment channels. Most of my patients come with moderate to severe levels of illness,” shares Dr Jan.
One has to wonder what a preference for faith healers or belief in supernatural possession, in spite of relatively good literacy rates, indicates about the overall level-headedness of a culture. The writer of this article was witness to an incident in which a faith healer declared that black magic had been performed against a patient who had been diagnosed with conversion disorder already. After ‘exorcising’ her, he left instructions that she should avoid being around menstruating women or eating food prepared by them. The ritual ‘impurity’ of menstrual blood was seemingly too powerful for his counter-spell of benevolent magic.
Superstition is only one of the obstacles in the way of people with mental health problems in need of support. Dr Farzana Niat Jan says that mental health is “the most ignored and stigmatized but critical and fatal issue.” In women, mental health is linked to other taboo issues like domestic abuse, forced or early marriages, and a woman’s place within the institution of marriage.
What we know so far – a look at the numbers and the causes
Suicide is a very complex phenomenon with multiple biological, social, economic and personal aspects. It is the 15th leading cause of death globally, with over 700, 000 deaths every year. The high rate of suicide in Gilgit-Baltistan in the first six months of 2022 has forced everyone to take serious notice of the issue. Sixty-five suicides this year so far outnumber the annual rate of any single year since 2005.
The main source for suicide figures of GB is the records maintained by the Police Department. This data was shared via the Population Welfare Department with a Mission of leading experts from the Aga Khan University who travelled to GB in September 2022 in order conduct a situational analysis. The figures were then publically shared at the Consultative Planning Workshop for the Development of a Mental Health and Suicide Prevention Strategy for Gilgit-Baltistan. This team of experts included Dr Zul Merali, Founding Director of the Brain and Mind Institute of AKU; Dr Sameen Siddqi, Chair, Department of Community Health Sciences; Dr Murad M. Khan, Professor Emeritus at AKU and a suicide prevention and mental health consultant; Dr Nargis Asad, clinical psychologist and Chair, Department of Psychiatry; Ms Falak Madhani, Head of Programmes and Research at Aga Khan Health Service, Pakistan; and Ms Maryam Pyar Ali Lakhdir, epidemiologist at the Department of Community Health Sciences, AKU.
In only 7 out of the last 18 years, women’s suicide rate was higher than that of men. Overall, more men took their own lives than women in GB from 2005 till 2022. In recent years, more diligent investigation of reported suicides of women has helped uncover honor killings. Proper categorization is essential for the formulation of strategies to counter both.
The data shows that “housewife” was the second most common occupation of those who died by suicide. Additionally, the majority of women took their lives outside the home while men did so at home. Furthermore, 86% of women who had died by suicide fell in the age group of 15 to 39 years. This begs the question if the home has become such a place of oppression for younger women that they may take extreme self-destructive measures to escape it.
Research in other parts of the country has shown that women in Pakistan are two to three times likelier than men to suffer from common mental disorders. Discrimination naturally results in poor physical and mental health. A pilot study by Dr Murad M. Khan and other researchers has demonstrated that younger women who are dissatisfied in marriage are more at risk of common mental disorders. Dr Khan’s Intergenerational Model of an Unhappy Married Pakistani Woman traces the impact of an unhappy mother who views her son as a surrogate husband, in terms of the social and financial security he provides, on the daughter-in-law who in turn becomes an unhappy mother herself, thus perpetuating the cycle. A number of factors come into play which may increase the strains on a married woman, including economic dependency, domestic violence, infertility, the pressure for having a male offspring, etc. Among other things, Dr Khan points out the need to redefine the mother-son ‘nexus’ to address these issues.
There is need for such studies to be conducted in Gilgit-Baltistan to reach accurate findings regarding risk factors for women of the region. Access to means is also a key area of intervention for the prevention of suicide. However, the majority of women simply jumped into the river. Nature is a means too powerful and elusive to monitor or secure against. This should help realize that effective intervention at an earlier stage is of utmost importance.
Ms Sosan Aziz, representative of Gilgit-Baltistan in the National Commission on the Status of Women, points out the repercussions of power play within family units. “There may be women-on-women violence in a struggle for power. Mothers want to exert ownership over sons, due to personal as well as economic motives, while wives also want to be empowered through the husbands.” She also shares her observation of hyper-sensitivity in young people. “We are bringing the children up in such a way that we only teach them to win. We don’t teach them the possibility of defeat or loss. We only envision win-win situations. In this way, we make them weak in the face of difficulties. We don’t prepare them for the trials and tribulations of life,” she says.
Clinical psychologist Dr Nargis Asad notes that aspects of suicide can be classified into financial and psycho-social. “Academic pressure, parental and teachers’ expectations, and career choice seem to be central in determining sense of worth for young males. For women, the most striking aspects include relationship with in-laws, incompatibility with husband and his family as women may be more educated, division of labor at home e.g., working women expected to contribute in the household tasks, and gender role expectations. Financial factors maybe more prominent for men whereas interpersonal factors, restrictions or family expectations maybe so more for women,” Dr Asad explains.
As for the particular topographical, environmental and other determinants of mental health and suicide particular to GB, Dr Asad emphasizes that empirical data is still needed to establish the risk factors in the region. At the same time, she learnt during her visit about the normalization of death and suicide in local languages through curses and swearing. It is a region that has been undergoing rapid social, cultural and economic changes over the last few decades. Dr Asad explains that “socio-cultural transitions have positives as well negatives, in that people can suffer from cultural shock, there can be clash of values between the older and younger generations creating disturbances at the household levels and society as a whole. Transitions can complicate gender and class issues which can lead to poor coping and adverse mental health outcomes.”
Ghizer is a district that has repeatedly featured in the news for rising suicide cases over the last few years. Dr Farzana Niat Jan notes that the overwhelming majority of patients she treats in her psychiatric practice in Ghizer are women. Women usually present with depression and obsessive compulsive disorders, while men often show signs of anxiety disorders. She finds suicidal ideation to be a common symptom in her patients, both men and women. “Nearly 45% of my patients have it. I conduct a suicide risk assessment to see how high the risk is. I provide supportive psychotherapy and start medication as soon as possible. I inform the family of the risk and advise them to not leave the patient alone and to take away any possible means using which the patient may harm themselves. I advise frequent follow ups. Patients who came to me with suicidal ideation or previous attempts are now in remission and improving,” Dr Jan shares.
Public health practitioner, researcher and activist Anayat Baig is a prominent voice on issues of mental health and suicide. “There are a lot of impulsive attempts,” he observes. Having battled through his own mental health struggles, he traces the roots of the problem to the home. “There is over-strict parenting. Homes feel like prisons. Nurtured behavior learned from social institutions is creating conditions that nudge people towards suicidal ideation and attempts. There is also a lot of domestic violence. Regarding women, there are cases of harassment and blackmailing.”
A source from the Cyber Crime Wing of the Federal Investigation Agency corroborates the incidence of suicidal ideation and attempted suicide in women as a consequence of blackmailing, revenge pornography and cyber stalking. “Young men and women share intimate content with their partners during a relationship. If the relationship ends, sometimes there is blackmail from one of the ex-partners as revenge,” the source shares. “When victims of blackmail reach out to us, they often express suicidal ideation, as they feel cornered and unable to see a way out. One such young woman actually attempted suicide. Another declared in my office that she was ready to jump off a bridge unless her problem was solved. Such young women are afraid that their own family members may kill them. It can also be difficult to prove the original culprit when content goes viral on social media. We need to have sufficient evidence to present in a court before being allowed to seize the cell phone of a suspect. Even if the case doesn’t go to trial, we make sure to erase the content from all sources as far as possible in order to help the victim.”
Other than disgruntled former partners leaking intimate content, there are also cases of hacking of women’s social media accounts after which they may be blackmailed and extorted. Unfortunately, social norms and family dynamics make the victims feel like they cannot share the problem with anyone. FIA has been conducting public awareness sessions regarding the risks of sharing personal data online. Sensitization needs to be scaled up to educate people on cyber security and newer forms of harassment in the virtual sphere.
Suicide is preventable. However, concerted efforts are needed in order to design and implement any effective prevention strategy. There have been multiple announcements of formation of government committees and commissions for prevention of suicide since 2017. The latest push for this kind of action came from the youth of Ghizer when they held a Grand Youth Marakah (community meeting) in June 2022. The event organized by Immune Commune Research and Development (ICRD) was attended by representatives from government, civil society organizations, educational and religious institutions, and more than 700 young men and women of the district. Youngsters got an opportunity to share their problems. While women participated in this event, they found it more comfortable to share their concerns on a one-on-one basis in private with the organizers. This activity resulted in a declaration of 21 demands, including a demand for declaring a mental health emergency in GB.
There were some objections raised on the committee formulated after the Marakah. Concerns were shared about representation of women and grassroots community workers. Anayat Baig shares this dissatisfaction. “Committees are formed, but a lot of the action is on the cosmetic level after there is hype following an incident. Mental health has never been a priority. Funds have been announced for suicide prevention in Ghizer but we are afraid that the amount will go towards bureaucratic expenses. Our suggestion is that the projects should be outsourced for better accountability,” he says.
The recent Review Mission of experts from the Aga Khan University that visited GB to conduct a situational analysis at the request of GB government, through the particular interest of Chief Secretary Mr Mohyuddin Ahmad Wani, has given hope for the initiation of a scientific approach towards mental health and suicide prevention. It indicates a level of seriousness and pragmatism that has not been seen previously. The focal person for this exercise, Director Population Welfare Department Mr Ikramullah Baig, explains that its purpose was to bring experts and stakeholders together to “help the GB government in developing an evidence-based suicide prevention and response strategy, identifying the areas where interventions are needed and how those interventions should be designed. We will also have to determine all the sectors which should be involved and whether to take a programmatic approach or a departmental approach.” Mr. Baig appreciated support from the Chief Secretary and the Inspector General of Police, Gilgit-Baltistan in providing access to available data and figures. While the data was segregated by gender, age and occupation, the inclusion of other gender-related variables such as marital status, number and gender of children, education etc may help create a better understanding of situations pushing women towards extreme actions of desperation.
The AKU team shared their key findings at a consultative workshop in which members of civil society, representatives of education and health sectors, and journalists participated. The findings were categorized into socio-cultural, economic, governance, regulatory and security, health and education, information and communication-related factors. The participants of the workshop shared their own observations and recommendations such as the need for help lines, community engagement and sensitization of parents. Sensitization and training of Lady Health Workers was suggested in order to optimize early detection in women. Dr Zul Merali appreciated the suggestions. “We are going to synthesize and combine your top priorities in a very multi-sectoral way… We need to have interventions at all these levels (of mental illness), not just (for) those people who are desperately ill and are taking their lives,” he said. A complete action plan based on the outcomes of the AKU Mission is to be shared with the Chief Secretary.
Prevention, help and the ethics of it all
The AKU situational analysis revealed multiple obstacles and complicating factors for those at risk of mental health or suicide, including stigma associated with mental health problems, communication gap between parents and children, academic and economic pressures, and a lack of avenues for healthy expression of feelings. Not only is there stigma attached to suicide, but it also remains a criminal offence in Pakistan. Gaps and weaknesses in multiple departments were identified, such as irresponsible reporting by the media, lack of physiatrists and a psychiatric hospital in all of GB, lack of training of educators and parents for early detection of warning signs, lack of reporting of suicide from hospitals and over-reliance on police for data, and underreporting from some districts. There is also an absence of a code of ethics for researchers and a lack of interventional research to find feasible solutions.
Ms Sosan Aziz emphasizes that “We need to give young people awareness and guidelines for seeking help. There should be platforms for communication, for sharing and reaching solutions. We don’t have such structures in the family, community or society as a whole. We generally avoid sharing anything personal. This kind of repression can even result in a minor matter exacerbating into a major problem. We should have psychiatrists available, both male and female. Women would feel more comfortable sharing their problems with a woman expert.”
There are some who think that discussing the topic of suicide publically would make things worse by planting the idea in the minds of susceptible youngsters. Anayat Baig disagrees with this. “It is not a matter of how much we talk about it. It is a matter of how sensitively it is done. The problem would not be exacerbated by sensitive discussion,” he says. He recognizes what he calls the “double burden” on women. “Mental health is already a taboo topic, and it also has a gender aspect,” he points out. He recommends the lay counseling model of mental health through which community members may be trained on basic lay counseling techniques. “They can then help each other in their circle of friends by listening to one another. This should be done on a mass level, at religious centers, community centers or any other existing platform.” The traditional reaction of panic or denial to suicidal ideation verbalized by someone in distress needs to be replaced by a culture of listening without judgment, reassurance, sharing of information, encouraging them to seek professional help, and disassociating the concept of shame from mental health issues.
Dr Murad M. Khan emphasized at the consultative workshop that solutions and prevention strategies must be localized to the particular context of GB. He also shared some of the general protective factors against suicide, such as religion, children, family, self-esteem, resilience, connectedness and employment. The higher the presence of these elements in a person’s life, the less likely they are to die by suicide. Women in general are under greater stress but also display greater resilience and will to live. This may be linked to catharsis through sharing or asking for help, which is less acceptable for men. Dr Khan stressed that a suicide prevention strategy for GB must be integrated, inter-sectoral, multi-layered and within a national mental health plan. It must be allocated appropriate resources, have proper monitoring and evaluation mechanisms and be informed by local research.
Suicide usually receives a lot of attention in the media in GB, both on formal platforms and on social media. However, there are multiple flaws in the methods of coverage and analysis including, it must be admitted, in past reporting by the author of this article. The bad news is that mostly we have been doing it wrong. The good news is that we can learn to do better. It is the responsibility of every reporter and media organization to educate themselves about basic dos and don’ts while reporting on suicide. The Associated Press does not cover suicides unless it involves a well-known figure or there is an element of public disruption. GB media outlets can also formulate informed policies and sensitize their reporters accordingly. Contents of suicide notes, details of methods used or the exact location of the incident should not be given. The verb “commit” should not be used with suicide so as to not criminalize the act. It should be presented as a public health problem, and sensationalizing headlines or romanticizing descriptions should be avoided. Information about the person involved should be kept general. Speculation about the reason behind the action should be avoided. Particularly in the case of a woman’s suicide or murder in places like Gilgit-Baltistan, it is all too common to associate the incident with her ‘character’. Clinical psychologist Dr Nargis Asad warns that suicides should not be flashed as “breaking news” and that journalists should not interview survivors of attempts. It is important to keep in mind that those who have made previous attempts are more at risk.
While it is commendable that concrete steps for suicide prevention are being taken in Gilgit-Baltistan, we must not forget to keep research, discourse and implementation nuanced, compassionate, scientific and sustainable. Women’s overall suicide rate is lower than that of men in the region, in keeping with global trends. However, suicides in women are often linked to gendered disadvantages for which there is little sympathy or support in the existing structures of the family and community. In addition to wide-ranging data collection for suicide in general, focused studies are also needed to explore the phenomenon in women while taking into account variables like socio-economic status, education, marital status and level of satisfaction within marriage, relationship with in-laws and incidence of domestic or intimate partner violence. Gilgit-Baltistan must tackle this public health issue with determination and foresight. The time for knee-jerk reactions is long past. The culture of blaming and shaming those who suffer from mental health problems must be eradicated. The young men and women of GB need to emerge from the darkness of frustrated hopes and lead the entire region into a more compassionate future.