Before Luh Ketut Suryani leaves paradise, she applies lipstick in the rearview mirror of her SUV. Suryani wants to look good when she encounters the horrors of the day. On this particular morning, she selects a deep red color.
Then she takes her iPad from the passenger seat and spends a few minutes in preparation. Calmly moving her fingers across the screen, she reviews the medical histories of her patients, including their names, how long they have been kept locked up, and their diagnoses. Some of the case histories are 30 pages long, an attempt at order in the face of madness.
Komang, in chains for the last eight years: "A mother, in a shack next to the cowshed. After her divorce, she wandered naked through the village for nights on end."
Ketut, in chains for 19 years: "A construction worker, a bamboo cot in the jungle. One day he tried to kill his brother. No one knows why."
Kadek, locked up for the last 24 years.
Her hand stiffens.
"A farmer, a windowless shack. When her mother died, she took a knife and went into the street. There are worms eating their way through her stomach. Diagnosis: schizophrenia. She is dying."
Suryani, 68, with six sons and 17 grandchildren, is a pleasant woman with a face as round as the moon. She is a psychiatrist on the island of Bali, a vacation paradise for some, hell on earth for others.
Her patients cower next to trees, lie in shacks, and are abused and sometimes forgotten. Because their relatives are overwhelmed by the care they require, because the healthcare system doesn't work and because insanity is seen as a punishment by the gods, people with mental illness live like chained dogs in Bali. There are 350 such cases in Bali and up to 40,000 in all of Indonesia. The Balinese refer to them as "pasung," or "in chains."
Suryani has already freed 52 people. Komang is not one of them.
A Shack Next to the Cowshed
On this morning, Suryani drives to the northern part of the island. The roads circle around like the patterns on a snail shell, with rice terraces in various shades of green to the left and right. The palm trees are shrouded in fog, and it smells of rotten fruit and soil. The sun is high in the sky when she arrives at her destination near the mountain village of Lovina Beach.
Six families live there, together with their pigs and chickens. And then there is Komang, whose right wrist has been attached to a one-and-a-half-meter (five-foot) chain for the last eight years. The other end is attached to a post, in a shack next to the cowshed.
Komang, 26, is naked, cowering inside the hut. She is singing a song in a high-pitched voice. She pounds her fists against the wall. Perhaps she is trying to drive out the voices in her head. She also tries to drive out Suryani, who is standing in front of her door, next to a box of drugs. Suryani, perspiring, remains motionless. Eventually she says: "Psst, my child, it's okay."
The windowless hut, all two square meters (about 22 square feet) of it, is made of concrete. There are several items on the floor: a pink mat, a pair of underwear, a wooden plow, a toothbrush, a comb, a tape measure, an oil can and a nail brush. A bee's nest hangs from the ceiling. There is a trail of ants next to the mat.
Komang hasn't bathed in two months. She is unable to express what she thinks or what she needs. But when Suryani looks at her face, Komang returns her gaze.
"Komang is always naked," says the brother, whose body is muscular from hard work. He and his sister used to play together by the river and hide in the fields, and when Komang was afraid at night, he would hold her hand. He was the one who chained his sister when she ran away naked.
'An Evil Spirit'
The brother grows rice and soybeans, supporting his elderly mother, his disabled sister, his mentally ill brother and Komang. The family owns two bamboo huts. A meal of rice and greens is cooking on the fire. They subsist on the equivalent of €1.30 a day.
"Komang was a normal girl," says the mother. "But when she turned 12, she was possessed by an evil spirit."
The sister-in-law says: "She was married at 18. Her husband brought her back. He kept her child. She has been screaming ever since."
"Komang is with the cows," says the disabled sister.
"Bring me a chair," says Suryani. She often spends hours talking with the families before beginning treatment. She asks about the patients' symptoms, their childhood and whether they have nightmares. But many don't know what is wrong with their mentally ill family member, or why he or she began to change. One day the family member simply becomes unhinged. When that happens, the families lack the time to cope with the problems, and they are often helpless. They try to protect themselves from the sick individual and protect him or her from the anger of the community, which explains the chains.
Asia isn't the only place where pasung exists. The practice is also known in Somalia, Nigeria and Sudan, countries plagued by civil war or terror and possessed of poor infrastructure --societies in which people believe in spirits. Where money and knowledge are in short supply, the mentally ill are often treated like the festering discharge of the system that produced them. Some literally rot away while still alive.
But there are few places where tourists and pasung are in such close proximity to one another as in Bali. Every year, three million tourists visit the island, where they go surfing and diving, get massages during the day and party in the clubs at night. Tourists come to Bali to unwind, oblivious to those locked up in chains because they are mentally ill, only a few hours' drive from the island's resorts.
Losing Hope in Recovery
Suryani's mission on behalf of the chained began when several bombs exploded in the village of Kuta in 2002 and 2005. She was director of the department of psychiatry at Udayana University in the capital Denpasar at the time. She had heard that suicides had been on the rise in villages after the bombing so she decided to travel into the hinterlands to investigate the causes. Although her effort was unsuccessful, she found a confused man attached to a chain next to a chicken coop.
She had never seen anything like it. "Why do you do this?" she asked. The relatives told her what it was like to lose a person, and then to lose hope in his recovery. They said that the chain was the only solution they could think of.
Suryani, witnessing the mentally ill in chains, in her island paradise, was so horrified that she founded the Suryani Institute, a private practice in Denpasar. Using the money she had earned treating affluent patients, including tourists, she hired seven employees. She sends them to two of the nine Balinese districts, one in the north and one in the east, which are most afflicted by poverty. Their mission is to track down the chained mentally ill. When they find one they call Suryani and she gets in her SUV. They found Komang in 2008.
On this particular day, Suryani is standing in front of Komang's hut for the 38th time. "What have you eaten?" she asks. Komang continues to sing. Suryani believes that Komang suffered a trauma, but she doesn't know what caused it. She has to assemble her diagnosis like a puzzle. Perhaps it was sexual violence, or a genetic defect. The family claims she ate poisoned food. "Komang didn't love her husband," says the mother. The gods, she explains, gave her this affliction as a punishment.
Suryani often diagnoses schizophrenia, both manic and bipolar. The word feels like a catchall for everything that can't be explained. But perhaps the diagnosis isn't really that important for the patients, especially given that therapy is hardly an option under these circumstances.
Suryani prescribes several drugs for Komang: 1.5 mg of fluphenazine, 2 mg of trihexyphenidyl, Sakaneuron, a neuroleptic agent against hallucinations, a drug to treat motor disorders and vitamin B.
Government Attempts to Treat the Ill
An injection with a neuroleptic agent, which has anti-psychotic properties, costs €7.50 in Bali, more than most families can afford. To offset the cost, Suryani buys the syringes, and sometimes she receives donated pills. The government provided Suryani with a $500,000 grant in 2009.
She also offers courses on prevention and teaches the Balinese how to meditate. Hundreds of people attend her Saturday sessions in Denpasar, where they lie on the floor, laugh for four minutes at a time and sing a song to combat loneliness. "Go outside your huts and breathe the air," Suryani tells them.
The government cancelled Suryani's grant after a year because the results of her work were not immediately apparent. Instead, it paid for the construction of sheds with bars on the windows, where families can lock up their sick relatives when they have attacks. Komang is always in one of these sheds.
Five people hold down Komang so that Suryani can administer the injections. She defends herself, pounding her chest and her private parts. When the drugs take effect, her speech becomes more intelligible. She utters short phrases, like "I'm sorry," "an evil spirit," "my brother," "why am I like this?" "please forgive," "Komang, Komang, no," "take off the chain." Sometimes her voice becomes high-pitched. Once she says: "chicken nuggets."
As she is leaving, Suryani says: "Wash her. Sweep out the fecal matter." The family members stare at the ground. Later, Suryani writes in her computer file: "Recommendation for Komang: love and attention."
Every four to eight weeks, she administers drugs to her patients, the first step on the path to liberation. She wants the relatives to become confident enough to remove the chains, as soon as the patients are stable. Komang was once free for a few months. She was in better shape, and her family sent her to work on a farm. But her boss brought her back, saying that all she did was stare at the wall, instead of pulling the seeds out of chili peppers. The brother chained her up again.
The issue, says the psychiatrist, is that society only takes notice of the mentally ill when they become a problem. As soon as they improve, the families forget to administer the drugs. Suryani could call the police whenever she finds people in chains. Pasung is illegal in Indonesia. The government has adopted a program that aims to eliminate pasung by 2014, but Suryani finds the plan laughable. And she doesn't notify the police, either. "Where exactly are the police supposed to take the patients?" she asks.
Filthy Mattresses and the Stench of Urine
The Indonesian government does little for the mentally ill. There are 48 psychiatric hospitals with a total of 7,700 beds in the entire country, which makes one bed for every 32,000 inhabitants. According to the World Health Organization, about 85 percent of all patients with mental disorders go untreated in developing countries.
Bali has only one government-run psychiatric hospital, in Bangli in the middle of the island. Treatment is free, and most of Suryani's patients have been there before. Two psychiatrists, and 10 doctors and nurses attend to the needs of 400 patients.
The hospital is currently a construction site. Additional wings for drug addicts were just built, says one of the doctors. He is wearing turf shoes and looks like a bad-tempered Scrooge McDuck.
The Bangli psychiatric hospital resembles a prison, and yet it is one of the better facilities in Indonesia, especially as there are no chains. Some 30 patients are kept locked up together in a room with bars. Men and women are housed separately, and each patient has a bed. Some are lying listlessly on their sides, while others walk around in circles or stare at the wall. There are filthy mattresses in the hallways, and everything reeks of urine.
When the doctor is asked what his patients lack, he says: "schizophrenia." And when asked about therapy, he says: "Sometimes we talk to them."
Friendly nurses stand in front of the cells, meticulously writing the name, age, diagnosis and medications for each patient onto a board with magic markers. The patients stay at the clinic for one to two months, say the nurses, but then they have to leave. "We have a drop-off service," says the doctor. If a patient isn't picked up, the employees from Bangli drop off the patient at home. Many are then immediately chained up again.
Ketut, one of Suryani's patients, is one of them. He has been living in chains for 19 years, an old man lying on a bamboo cot in the forest. He tried to kill his brother. He has been to Bangli many times, and he is handcuffed whenever the doctors pick him up. When he is returned, his brother-in-law chains him up again. The family is afraid of Ketut. They throw him food, drinks and cigarettes from a distance, as if he were a dangerous dog. At least he is in good physical condition. "He was lucky," says Suryani.
It's afternoon when she walks into the courtyard in front of the house where Kadek and her family live, which is near Singaraya in northern Bali. It's Suryani's first visit. Her employees, who found Kadek, have been there already. Kadek's father is a rice famer, and her brother takes tourists to see dolphins. Kadek, 42, is going to die.
Her father has placed her on a sofa. There is a spirit's mask on the wall behind her. He has placed his hand on her leg, which is as thin as a broomstick. Kadek doesn't speak or make any noise at all. The father says that her stomach is full of worms. Suryani switches on a recording device to document the woman's history. The father tells Kadek's story.
When Kadek was a young woman, she loved arithmetic. She spoke very little and wrote numbers into a notebook every day. When her mother died, Kadek tore up the notebook. She stopped speaking. She took a portrait of her mother from the bedroom and stared at it for days on end. Later she took her uncle's motorcycle and drove away. She took a knife and went out into the street with it. She undressed and jumped into a dirty river. She smeared her feces onto the walls. She tore up her clothes, and one day she kept hitting a mirror until her fists were covered with blood.
"Black magic," says the father. The family had managed to accumulate a small amount of money. "We were doing too well," he says. "This is our punishment."
Like most people in Bali, Kadek and her family are Hindus. They believe that mental illness is caused by evil spirits, and possibly by a curse imposed by their ancestors. Kadek's father says that he has taken his daughter to 57 healers, known as balian, in the last 24 years. The healers decide whether a case of insanity is something supernatural or a physical problem. Depending on their verdict, they say, the treatment should consist of either Western medicine or traditional rituals.
A Dark Hut
In most cases, the balian chooses a ritual. Kadek has experienced many of these rituals, in which the family sits in the village temple and prays, with the sick family member in the middle. The healer mixes together flowers, essences and water. When he sprays the mixture, the patients begin to shake, rolling their eyes or rolling on the floor. It looks like an exorcism. According to tradition, a person possessed by a spirit is innocent and can be cleansed and made normal again. Kadek, says the father, cannot be cleansed.
He has hung masks all around the courtyard, creating a protective temple for Kadek. "It doesn't do any good," he says. Then the father shows the psychiatrist his daughter's room, a bleak space with a window and a card game on the table. Suryani notes the words "schizophrenia" and "anemia." Kadek weighs no more than 30 kilograms (66 lbs.).
Suryani gets back into her car and slams the door shut. She drives to the village health clinic and says: "A person is dying 500 meters from here."
The director of the clinic says that nothing can be done. As long as there is tuberculosis, malaria and infant mortality, schizophrenia is a problem for the gods, he says.
Later Suryani returns, unannounced, to the courtyard in front of Kadek's family's house. It turns out that the father had lied. The room he had shown Suryani isn't Kadek's room at all. Instead, she is lying behind the house, on a wooden stretcher in a dark hut. The tiles in the room are stained brown from her feces. The plaster is peeling from the walls, and there is a bowl containing a handful of rotting rice. Kadek is naked and her eyes are half-closed. Her legs are crossed and her right foot is constantly twitching. Perhaps it's her last sign of life.