uring our last skirmish with our eastern neighbour, when drones were whistling over the skies of Lahore, I had a chat in our clinic with some students. One of them, a very intelligent young woman training to become a psychiatrist, asked plaintively what a psychiatrist could do in times of war. I pointed out the obvious: all battles are first won, or lost, in the mind. Keeping everyone’s spirits up in times of crisis is what we do best. It is something I often come back to.

Shrinking space for dissent or debate, political uncertainty and an atmosphere of fear and intimidation have created a chronic, low-grade despair. This is often attributed to lack of faith, weakness or ingratitude. But despair or anxiety in reaction to actual dire circumstances is not weakness. Medication can treat an illness; it cannot, on its own, repair the circumstances that produced it.

When distress is dismissed as a private failing, the conditions behind it go unexamined. This is precisely where the problem lies.

As we approach yet another global Mental Health Day, we are still ignoring mental health: a health budget with no line of its own for mental health, in a country with less than 1,000 qualified psychiatrists—about 0.19 for every 100,000 people, according to the WHO; families who are still afraid of log kya kahenge (what will people say); and patients who are still told that sadness is a failure of faith.

“It can’t be done,” my wife said. We were talking about starting our own mental health clinic after years of renting spaces here and there. The year was 2022, and Pakistan was being consumed by an inflationary fire the likes of which I had never seen. Within a year, the rupee had lost nearly a third of its value. Petrol prices skyrocketed. Inflation would peak at 38 percent in May 2023. We talked to some banks but it was futile.

Eventually, we begged and borrowed from family and close friends, and managed. I am a senior doctor at one of Pakistan’s most renowned medical universities. If I was struggling, what must the average person be going through?

In the United States, we were taught to translate social phenomena into economic costs. Sick people take more time off work. Presenteeism is unique to mental health: a person is physically present but cannot focus or find the energy to begin or complete work. They are not absent, but they are at less than full speed. This, too, comes at a cost—to them and their employers.

In our teaching hospital, one of Pakistan’s largest, we often bemoan our lack of resources. But here too there is a paradox. One of the most common presenting complaints in mental illness are physical symptoms: chest pain, shortness of breath, aches, stomach pains, indigestion. There is nothing physically wrong, or so it seems. Yet the patients keep returning to our overflowing emergencies and clinics. Tests keep being repeated, sometimes leading to surgeries, and the precious time of doctors and nurses is consumed to little avail. These complaints jumped dramatically just as Pakistan fell off the economic cliff in 2022. These patients need mental health treatment, not more tests and surgeries. That is an unneeded and easily remediable cost to families and all of us as a society.

Then came another cost: despair.

The steady trickle of people moving abroad turned into a flood. I personally met dozens of patients and students, doctors and nurses, who were in the process of leaving. Official figures show more than 830,000 workers registered to go abroad in 2022; over 860,000 in 2023, including more than 3,000 doctors. Most go for better wages. But I hear another reason every day in my classrooms and in my clinic: despondency.

We are one of the youngest countries in the world. Nearly two thirds of our population is below thirty. I call it our demographic treasure. We are squandering that treasure with both hands by refusing to give them the education and skills they need for the jobs of tomorrow. Why are we surprised at the epidemic of mental health problems among the young, up to and including suicide, especially in regions such as Chitral and Gilgit-Baltistan?

The WHO reported a 25 percent rise in anxiety and depression worldwide in the first year of the pandemic. With wars ongoing and whole populations displaced by climate change, this is set to rise sharply.

In our hospital, we teach healthcare workers about the cost of work stress and burnout. I see it every day: colleagues who want to quit and leave Pakistan, and young medical students despondent about their future, sometimes to the point of wanting to end their lives.

None of this is beyond remedy and the solutions do not cost much. Train primary-care doctors and lady health workers to recognise depression and anxiety. Put counsellors in schools. Give mental health a budget of its own. And say, plainly and often, that distress in hard times is a sane response, not a defect.

At our recent Global Mental Health Summit in Islamabad, we pledged, along with representatives from the federal and provincial governments, academia and international partners to do better.

Asking people to keep on hoping for better times while their lives crumble around them is dishonesty. We need to do more to actually change their lives for the better.

The writer is a faculty member at King Edward Medical University. His latest book is Secrets: Stories of Psychiatry from America and Pakistan (Sang-e Meel Publishers). Read more at his blog https://alihashmi.substack.com/