Nearly 19,000 people in Indonesia diagnosed with mental disabilities are currently living shackled in chains or otherwise confined to claustrophobically small spaces — one symptom of a national mental-health-care system characterized by systematic shortcomings and retrogressive science. That’s according to a new report released by Human Rights Watch on Monday morning local time.

The report, succinctly titled Living in Hell, provides a grim portrait of Indonesia’s neglect and abuse of its mentally ill population. It pays particular attention to the practice of pasung — placing those with “real or perceived psychosocial disabilities” in “shackle[s] or locked up in confined spaces,” which persists across the country despite a national ban in 1977. According to the report, 18,000 Indonesians currently live in pasung, with viable mental-health-care alternatives either inaccessible or nonexistent.

The report notes that the culture of mental-health care in Indonesia relies heavily on backward pseudo-science rooted in dated spiritual traditions. The report’s authors observe a “widespread belief that mental health conditions are the result of possession by evil spirits or the devil, having sinned, displayed immoral behavior, or lacking faith.” (In Indonesia, many also condemn homosexuality as a mental disease.) Because of the stigma that shrouds mental illness, families tend to deliver their sick loved ones not to medical treatment but to spiritual healers.

Pasung is a hallmark of this method of “treatment.” In these cases, patients are constrained, often naked, and in many cases left outdoors for days to years. The Human Rights Watch report estimates that as many as 57,000 people in Indonesia — nearly 15% of all seriously mentally ill people in the country, by some estimates — have been subjected to pasung at least once (the figure is higher in rural regions).

On paper, the Indonesian government condemns this practice as inhumane. Six years ago, the country’s Health Ministry embarked on an ambitious mission to completely eliminate pasung from the country by 2014 — a deadline recently extended to 2020. In 2014, the parliament passed the Mental Health Act, a piece of legislation written to further the “promotion, prevention, treatment and rehabilitation” of mental illness.

However, this commitment has yet to yield tangible returns. Less than 1% of Indonesia’s national health care budget goes to funding mental-health-care treatment, according to psychiatrist and former Indonesian lawmaker Dr. Nova Riyanti Yusuf in an essay published in the Jakarta Globe last year. “There is a lack of political will,” she tells TIME.



The Human Rights Watch report also addresses the fundamental scarcity of the country’s mental-health-care resources: in a country of 250 million — it is the world’s fourth most populous nation after China, India and the U.S. — there are only between 600 and 800 psychiatrists, or one for every 300,000 to 400,000 people. There are also only 48 mental hospitals in the country, many of which are characterized by “severely overcrowded and unsanitary conditions.” At one hospital on the outskirts of Jakarta, the country’s capital, around 90 women live in a room built to accommodate around 30. The report documents rampant sexual and physical abuse ranging from unwanted sexual contact to subjecting patients to electroconvulsive therapy (ECT) without providing anesthesia.

Eight of the country’s 34 provinces have no mental hospitals whatsoever.

— With reporting by Yenni Kwok

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