Running the Asylum

A schizophrenic tries to save the mentally ill in Pakistan, a land gone mad.

Gulzar Wazir, 61, a retired Pakistani army major and the founder of Peshawar’s only community mental-health clinic, was introducing me to Raja, one of his favorite lunatics, when we heard the soft whine of a single-engine plane, flying low and getting closer. Northwest Pakistan—land of suicide bombers, kidnappings, and American drone strikes—is not a relaxing place, and the background violence is enough to nudge the merely jittery into little episodes of paranoia. In the United States, that lawn-mower whine overhead might be a student pilot getting his wings, or a cardiologist at play. Here, for a visitor with dangers on the mind, it sounded like death from above, and it gave me a shiver.

What does it take to be counted as paranoid in such a place? “The question is not ‘Who is mad?,’” Wazir says. “The question is ‘Who is not mad?’” All of Pakistan—a nation of 185 million people—has no more than 350 psychiatrists, or roughly the same number as in a few blocks of the Upper West Side.

Peshawar’s hospital for the mentally ill lacks the capacity to treat patients for more than a month. Wazir’s clinic treats them indefinitely. Currently supported by the government of Norway, the clinic has ministered to the mentally ill in the poverty-stricken Tehkal Payan area since 2004. Known to donors as “Friends of the Mind” and to locals as “the crazy-people hospital,” it sees about a dozen of its 5,000 outpatients on any given day. Some visit daily for medical care and tea in its courtyard. Psychologists are on staff, as is a full-time psychiatrist trained in China’s Henan province. Most patients are depressed, addicted to hashish or opium, paranoid, or schizophrenic—or worse yet, some combination of the above.

Raja, in his early 30s, is a typical case. He has been out of his mind and addicted to hash for most of his adult life. He’s tall and skinny, with a film of dirt on his face that suggests he can’t quite look after himself. Wazir says Raja routinely relapses by leaving the hospital and hanging out at a nearby shrine close to a police station, where addicts gather to smoke hash and opium. (Wazir blames the hash for worsening Raja’s mental problems. Research does indicate that some schizophrenics decline faster if they smoke hash. Other research, however, shows that cannabidiol, one of the psychoactive chemicals in hashish, has antipsychotic properties. Perhaps it’s a wash.)

Today is a good day for Raja. His eyes bug out, and his lips are pulled back in a huge grin that reveals teeth the color of brown sugar, looking so rotten that a swig of water might wash them away entirely. On bad days, he flies into uncontrollable schizophrenic rages. “If he is violent or too talkative or too mischievous,” Wazir says, “we put him again in the mental hospital, and if he requires it, he gets electric shocks.” He has gone through about 15 rounds of shock therapy. “But he’s young, so he can sustain it.”

Wazir says his countrymen have been mentally traumatized more or less continuously for the past 35 years. “First it was Afghan jihad, then it was Kashmiri jihad, then it was the nuclear issue, then it was terrorism and suicide bombings, and now floods,” he says. “I have not heard any good news coming to me in Pakistan.”

A native of Waziristan (a frequent target of U.S. drone attacks), Wazir is himself schizophrenic. He had a promising military career and became an adviser to General Zia-ul-Haq, then the president of Pakistan. In 1981, he began suspecting that Zia was plotting to kill him. “I was convinced that he had spies against me, that he was stealing my thoughts, that he wanted to court-martial me and arrest me,” Wazir says. Zia was, according to Wazir, himself terrified of plots against him, and was plotting against almost everyone. But on evaluation, doctors decided Wazir was indeed crazy, invalided him out of the army in 1983, and began a regime of medication that continues today. After recovery, Wazir resolved to set up an organization “for the mentally ill, of the mentally ill, by the mentally ill.”

Craziness carries a strong stigma in Pakistan, and many friends and families of the afflicted react by turning them out onto the street, or confining them. Wazir’s staff found one mentally ill man, Inam, chained in a basement. Now on his meds, Inam keeps returning to Friends of the Mind, but he has recovered enough to hold down jobs as a day laborer. Far better to be in the chaos of Peshawar’s streets and on the brink of insanity than in a basement and in the abyss.