Psychiatry, the State, and Interpretive Contests in Pakistan 

The civil unrest that occurred on May 9, 2023 across Pakistan is currently under investigation. According to Dawn, Pakistan’s most circulated English-language newspaper of record, at least eight people were killed, 290 were injured, and 1,900 protesters were detained after former Prime Minister Imran Khan from the Pakistan Tehreek-e-Insaf (PTI, or Pakistan Movement for Justice) was arrested from a court in Islamabad and remanded into the custody of the National Accountability Bureau on charges of corruption. Protesters attacked police stations, military installations, local branches of Radio Pakistan, railway lines, and residences of top officials, resulting in the deployment of troops in Punjab, Khyber-Pakhtunkhwa, and Islamabad. The Supreme Court of Pakistan declared Khan’s arrest “unlawful” and ordered his release on May 11, 2023.  Khan was arrested again on August 5, 2023 after a court sentenced him to three years in prison for illegally selling state gifts. 

The events marked the culmination of increasing political demonstrations after Khan lost a no-confidence vote on April 10, 2022 in the National Assembly of Pakistan, which toppled his government. The PTI and its opponents have conflicting narratives of these events and subsequent political disputes. This essay uses anthropological theories to analyze Khan’s medical evaluation, which the government conducted on May 9, 2023 during his detention. Examining how people use psychiatric knowledge to advance claims about “normal” and “abnormal” behaviors in public discourse can uncover cultural values and orientations.  

The Medical Evaluation for Former Prime Minister Imran Khan 

On May 26, 2023, Pakistan’s Health Minister Abdul Qadir Patel released Khan’s two-page medical evaluation at a press conference.  The document was titled, “Medical Fitness Certificate of Detainees at Police Station NAB [National Accountability Bureau].” The title denoted that the document served a medico-legal purpose, not a fiduciary interest that governs a doctor-patient treatment relationship.  

The first page consisted of the physical examination and results of a blood test. It noted that Khan’s “nervous system” was “intact,” his “higher mental function” was “intact,” and that his “clinical status” was “stable.” None of these findings indicated impairments. The second page offered an interpretative summary. Khan appeared “under stress with anxiety symptoms.” He exhibited “little insight about the seriousness and reality of the current situation.” Contrary to the first page, the second page stated that his “mental stability is questionable.”  

Five physicians signed the document. Three were affiliated with the Pakistan Institute of Medical Sciences in Islamabad, one of whom was the Head of the Psychiatry Department. Two others were affiliated with the Federal Government Poly Clinic. 

Figure 1 – Imran Khan’s Medical Evaluation from May 2023

The Reception of Imran Khan’s Medical Evaluation 

At the press conference, Patel acknowledged that the full medical report was not yet ready, but that because this was a public document, it was his “obligation by virtue of being Health Minister” to present several points. First, “the described” [Khan] walked with a heavy cast for five or six months despite there being “no mention of a fracture of his leg in the medical report.” On November 3, 2022, Khan described facing a gunman during an assassination attempt, with news footage independently capturing the moment when he was shot in the leg at a political rally. A suspect confessed to trying to kill Khan because he was “misleading the people.” Instead, Patel called Khan “the only person in the world” walking around with a cast when there was no evidence of his skin being pierced. Second, Patel acknowledged that a full urinalysis was not completed at the time the report was released, but that Khan’s preliminary urine toxicology showed “repeated use of alcohol and cocaine.” Third, Patel read out the interpretive summary and commented,  

“His mental status is not good… even after we set aside the cocaine, we set aside the alcohol, and we set aside the deceit of the drama of the fracture.” Patel added, “This is not the first time. A lot of you must be witnesses to when I went to the [National] Assembly when he was Prime Minister and said, ‘He is not right mentally. Put him in a museum because you won’t find anything like him.’ Because a narcissist tells a lie and then tells lies non-stop. He calls his lie the truth and tries to get others to believe it is the truth. And the conditions that have taken place over the past few days are not the result of a single day. No! This narcissist was preaching to the people for years. Ever since he was removed from government, he has been taking the youth on a path whose result you have seen.”  

Patel detailed the consequences for Pakistani society: “The custom [rivāj] of courtesy [shāyestegī] in our politics was destroyed from the first day. The fabric of your culture – the respect for mothers, sisters, daughters-in-law, daughters – has been destroyed. The scope of tolerating political differences within you has been converted into enmity.” Patel asked, “Is this the person whom a judge declared to be truthful [sādiq] and honest [amīn]?”  

Patel was using two terms – sādiq and amīn – that he knew would resonate with Pakistan’s citizenry. Despite requiring members of Parliament to demonstrate both virtues, the Constitution of Pakistan has not defined either term. The reason for this requirement comes from Pakistan’s historical evolution into an Islamic republic. In his desire to Islamicize the country nearly four decades ago, General Zia-ul-Haq amended the Constitution so that elected office-bearers would have to emulate the Prophet Muhammad. Some political commentators have criticized this amendment as a morality test that disqualifies political opponents and marginalizes non-Muslim minorities. Patel vowed to take legal action against Khan’s personal doctors for “wrong practices” of putting a cast on him when there was no evidence of a fracture while alleging that Khan was not sādiq and amīn.  

The report’s release polarized public opinion. Journalists and activists raised doubts: the report could not be considered reliable due to its contradictory findings; the quality of the interpretative summary was poor; and the physicians who signed the report seemed to be violating professional ethics. An anonymous source from the NAB told reporters that “[t]he medical reports as available with NAB do not endorse what the health minister alleged,” and that three independent physicians challenged Patel’s claims after reviewing the medical evaluation.  

Khan’s PTI released a video response on YouTube. A physician who described herself as “having lots of experience with mentally unstable patients who take drugs or get sent to retention centers” called the report “extremely funny.” She went through each line of the first page to describe all of his results as normal. Using the same vocabulary as the report, she termed “the mental stability” of the certifying physicians, their degrees, and “their fitness to practice medicine” all “questionable.” She dismissed the report as “fake” and wondered whether the physicians were compelled to sign it at gunpoint. The PTI hired a lawyer to initiate defamation charges against Patel and the report’s physicians for “baseless and unfounded allegations,” seeking damages of Rs. 10 billion [~USD $3.48 million]. Essentially, the PTI challenged how sādiq and amīn government’s officials were in producing Khan’s medical evaluation.  

The Interpretive Contests Over Psychiatric Knowledge in Forensic Settings 

The medical anthropologist Arthur Kleinman has suggested that psychiatric diagnosis is an act of interpretation because disorders are only diagnosed after physical examinations, laboratory investigations, and radiological imaging have ruled out non-psychiatric, so-called “organic” diseases. One enduring line of research in interpretive medical anthropology has examined differences between patients, who understand illnesses as disvalued states of being or functioning, and professional healers, who treat diseases as scientific abnormalities of bodily systems. As I have detailed elsewhere, adversarial court systems in which medical knowledge is used to answer a legal question, not provide treatment, exacerbate differences in patient-professional understandings because legal and medical experts undertake interpretive contests to explain a defendant’s behaviors. Imran Khan’s medical evaluation has sparked interpretive contests as government personnel pathologize his results and his party’s supporters underscore that there were no abnormalities on the physical examination or blood testing.  

In fact, the validity of the evaluation has been called into question. Patel claimed it was his “obligation” to release preliminary findings, which a physician consulting for the PTI deemed to be “fake.” This dispute recalls the medical anthropologist Emma Varley’s formulation of hospital paperworlds, in which: 

“Incomplete or skipped reporting resulted from the time constraints posed by work on a busy maternity ward. More complexly, it also stemmed from providers’ attempts to disguise medical neglect and error, and mismanagement and maltreatment, which could lead to them being held accountable for bad outcomes that were often—though not always—beyond their easy ability to prevent let alone treat in settings marked by profound scarcity. “Doctored” scripts and under-reporting facilitated providers’ professional and reputational self-preservation and afforded tactical benefits for hospital administrators.”  

A similar process can be discerned with Khan’s medical evaluation. Patel released an incomplete report without urine toxicology results based on political constraints. The PTI has vowed to hold the certifying physicians accountable for outcomes that were likely beyond their ability to manage, given the high political stakes. This case, of doctors potentially altering their notes, raises central methodological and epistemological questions in anthropology about how we know what transpires in medical settings if our knowledge is based largely on documentation. The role of health providers in determining whether public officials are sādiq and amīn is a topic that merits further examination in Pakistan.     

Finally, Patel labeled Imran Khan a “narcissist” several times during the press conference, even though no clinical documentation was released in support of this label. There is a clear difference in the way Patel conceptualized psychiatric disorders from other medical disorders. Had the medical evaluation revealed a fracture in the leg, perhaps it would have explained Khan’s wearing a cast for several months after the attempt on his life. But Patel viewed Khan’s politics as an unacceptable reflection of narcissistic personality traits. The medical anthropologist Lorna Rhodes has shown how mental health providers in criminal justice settings classify those whose behaviors are tolerated as “mad” and “sad” due to anxiety, depression, or psychotic disorders, as compared to those whose behaviors are derided as “bad” because of personality disorders. Clinically, we do not know if Khan has narcissistic traits, since he did not release his personal medical records and the government’s evaluation did not produce evidence of narcissistic traits.  

In fact, the political weaponization of psychiatry has increased worldwide. Recent examples include mental health professionals declaring US President Donald Trump to be “a clear and present danger” to the country, Brazilian President Jair Bolsonaro to display narcissistic traits for his handling of the COVID-19 pandemic, and Russian President Vladimir Putin to be a “psychopath” after the invasion of Ukraine. Each of these instances reflects a political use of psychiatry: clinical concepts are used to explain the behaviors of politicians without a direct psychiatric or psychological examination. By drawing upon the social authority of medicine, critics label behaviors that they disagree with as “bad” and ascribe them to personality traits that they view as negative. Using clinical concepts to criticize politicians downplays other ways of expressing disagreements in civil society, such as highlighting policy differences. Personality-based explanations also do not account for other explanations for behaviors in political settings such as group-based decision-making. Moreover, the political weaponization of psychiatry shows little compassion for millions of people around the world who live with mental disorders. 

Psychiatry as a Tool for Cultural Analysis 

Examining psychiatry as the product of a particular history and culture  facilitates deeper analysis of a specific society. As George Devereux argued, a fundamental dilemma in studying psychiatry is differentiating between normal and abnormal psychological phenomena, which is inherently a cultural exercise in judgment. In this respect, two points from Patel’s statements merit greater scrutiny as Khan’s political future continues to evolve. The first is gendered speech, where “respect for mothers, sisters, daughters-in-law, daughters – has been destroyed.” The second is the construction of Islamic morality. In Sovereign Attachments, Shenila Khoja-Moolji describes “Islamo-masculinity” as performances of heteronormative masculinity and Muslimness in public domains whereby texts inform popular opinions about governance: 

“Scripts of gender and Muslimness become the very means through which sovereignty is performatively iterated in Pakistan. Both the state and the Taliban recruit strangers into relationships of trust, protection, and fraternity by drawing on and reinforcing gendered hierarchies, kinship feelings, and normative understandings of Islam. Such relationships become the structure of feelings that permits the classic and everyday acts of sovereignty that we immediately recognize: violence and governance.”

In Patel’s telling, Imran Khan tore Pakistan’s “fabric of culture” by eroding respect for women. In this narrative, Khan could not be medically fit to govern because he transgressed relationships of trust, protection, and fraternity between rulers and the ruled. It remains to be seen how Pakistani politicians enact scripts of heteronormative masculinity and Muslimness with national elections slated for 2024. In addition, Patel’s claim that Khan has not been sādiq and amīn will now be tested in Pakistan’s legal system. Khan faces over 180 court cases, mostly in relation to the events of May 9, 2023. Medical anthropology offers a vital perspective to advance cultural analysis across societies by interrogating the use of psychiatric knowledge and practices. 

Neil Krishan Aggarwal is Professor of Clinical Psychiatry and a Member of the Committee on Global Thought at Columbia University. A cultural psychiatrist and social scientist, his primary areas of research are translating anthropological theories and practices for use in clinical settings, the anthropology of mental health and illness, and psychological anthropology.