Neuroscience is not only the last frontier of biology but also an area which, despite enormous need is among the most neglected in Pakistan. Understanding how the nervous system works, what toll the impairment of cognition has on an individual’s life and how cognitive abilities can be improved is critical to the quality of life. Pakistan must invest in basic and clinical neuroscience education to produce first-rate neuroscientists and neuroclinicians to research and treat the vast number of its unfortunate citizens who suffer from neurological and psychiatric illnesses.
Mental retardation and neurodevelopmental impairments
Brain disorders that impair our ability to learn, recall and think are among the most cruel diseases, and it is especially heartbreaking when children suffer from them. It is estimated that between 10 to 20 per cent of children worldwide suffer from one or more mental or behavioral problems. Approximately 39 per cent of the population in Pakistan is made up of children, age 0-14 years. Developmental disabilities start during childhood before the brain has completely developed to its full potential.
Not surprisingly, the prevalence of mental health problems among school-going children is high in most developing countries. The prevalence of severe mental retardation in developing countries is estimated to be 5.2 to 16.2 per 1,000 children; in Pakistan it is estimated to be 15.1 compared to three to five per 1,000 children in developed countries. As in other developing countries, a major concern regarding the identification and treatment of mental retardation and other neurodevelopmental disabilities (such as autism) in Pakistan is a proper diagnosis and combatting the stigma that surrounds it.
Neurodevelopment disabilities are often seen in general pediatric practice. While definitive data for Pakistan is lacking, clinical approximation suggests that over six million (10 per cent of 62.5 million) children are learning impaired, while close to two million manifest some degree of mental retardation.
The population prevalence of these combined disorders of learning rivals that of the common childhood disorder asthma. Most individuals with mild mental retardation and other learning disorders are free of neurological complications, CNS malformations, and dysmorphisms. They are more likely, however, to be born into families of low socioeconomic status, and little education. Poor cognitive functioning and mental retardation are correlated positively with a life of poverty. With a population growth rate of over two per cent, more and more children with mental retardation and neurodevelopmental disabilities are being born in Pakistan every year; a society which remains ill-equipped for early detection, support, appropriate treatment and follow-up of these individuals.
Mental retardation is broadly defined as having a significantly below-average score on a test of mental ability or intelligence and by significant limitations in the ability to function in areas of daily life such as communication, self-care, and getting along in social situations and school activities.
The term neurodevelopmental disorder covers a wide range of conditions and subcategories which arise during an individual’s childhood years, and continue across the entire life span affecting emotion, the capacity for learning and memory. Such disorders include mental retardation, Down’s Syndrome, cerebral palsy, attention-deficit and disruptive behavior disorders, autism, communication and learning disorders, neurological and psychiatric disorders. They are best treated when identified early in life so that proper care and support can be given to the affected individual by a system of support including the family, school, and medical care.
The problem with identifying this sort of disability in its early stages is that unless a trained eye looks for the signs and identifies it properly, it will often be overlooked as just a stage, or underestimated due to the social pressure of having an “abnormal” child. Therefore, it is very important to be informed about these disorders and then to make the right decisions with the help of trained medical professionals to better assist a child who suffers from a neurodevelopmental disorder.
Lack of trained personnel and institutions
Recent scientific progress has helped to better understand and address mental retardation issues. Recognising that people with mental retardation, with proper care and support, can be integrated effectively into larger society and can be valuable productive family members and citizens, has been probably the major achievement in reducing the social stigma associated with mental health disorders.
During the recent years, in developed countries people with mental retardation have increasingly been accepted as functioning members of society, many live in special community settings where they are employed and become productive, as well as accepted for their abilities. An excellent example in Pakistan is the Roshni Village Centre, a very small private funded project, supported by the Roshni Association in the outskirts of Lahore, where mentally retarded people are not only being taken care of, but are also increasingly becoming a part of society by producing goods on the farm and operating a bakery where organic baked goods are made and sold. Such projects need to be encouraged, multiplied and generously supported.
Proper medical care and strong social support give those suffering from neurodevelopmental disorders the opportunity to live life as normally as possible. In developed countries, social integrative programmes in which other children help to teach children with developmental disabilities social and learning skills and parents are trained to deal with attention problems or other individualistic problems, make a big difference in the lives of the disabled children and the social environment where they live.
In developing countries like Pakistan, the immediate family is usually the place where most of the neurodevelopmentally disabled live, mainly due to a lack of affordable social institutions to host them. However, for some more severe cases where specialised medical attention and supervision is required, the lack of access to adequate mental institutions makes the lives of both children with disabilities and their families very difficult. Therefore, it is important to offer a system of support both for the children and the family that includes social workers, child caregivers, and relief care centres.
It is the scarce availability of such centres coupled with financial constraints and lack of trained professionals in Pakistan that makes the status of people with mental retardation and developmental disabilities quite alarming. There is an urgent need for increasing the number of all levels of trained personnel working in primary care and at clinics. According to Murad Moosa Khan, Professor of Psychiatry at the Aga Khan University, “there are only 150-200 qualified psychiatrists in Pakistan, an alarming ratio of one psychiatrist to a million people. The majority of psychiatrists are urban-based, whereas 70 per cent of the population is rural-based” (Psychiatric Bulletin, 2006).
In addition to increasing the number of child and adolescent psychiatrists, there is an urgent need to address the lack of social workers and professional nurses (currently there is less than one psychiatric nurse per million people in Pakistan), as well as community facilities that can offer information and guide the parents and families of those with neurodevelopmental disabilities to adequately care for their children. These community services can offer a more useful and helpful model of care than that presented by the traditional healers that people go to.
The future: what may be done
Only 7.6 per cent of third-year medical students from four medical colleges, have selected psychiatry as their chosen career or as a highly likely choice, according to “Attitudes of Pakistani Medical Students Towards Psychiatry as a Prospective Career: A Survey” published in the April issue of the journal Academic Psychiatry.
The government currently spends only 0.4 per cent of the total health budget on mental health (WHO, Mental Health Atlas, 2005), and very little goes to higher education and training of medical staff specifically for mental health. Currently 17 institutions offer training in psychiatry, but the low passing rates and the poor quality of higher education, affects the quality of graduated professionals and their future professional work. With such numbers, the prospects of children with mental health problems are not very bright. Immediate attention and serious funding must be provided by the government both to educational institutions that prepare and train medical staff and social workers as well as to existing clinical institutions. In addition, new community-based centres where neurodevelopmentally disabled children can be taken care of should be established.
These three avenues can be facilitated by establishing public-private partnerships between government-funded institutions such as universities and hospitals (the main health care providers in Pakistan) and businesses or non-profit organisations interested in healthcare and education. Such partnerships have the benefit of attracting more funds and thus becoming more effective in providing better care to a larger number of children that suffer from neurological disorders.
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