Cokorda is not talking about the usual Southeast Asian problems of prostitution and paedophile rings, and few tourists would ever see the depravity of which he speaks.

On weekdays, Cokorda, a psychiatrist whose boyish face belies his 44 years, treats patients in the island’s capital, Denpasar. But on weekends he works pro bono with the Suryani Institute for Mental Health, a charity founded by his mother that offers meditation classes, elderly support, child protection and crisis relief for Bali’s poor.

It is best known, however, for rescuing victims of pasung – the Indonesian word for stocks – an ancient and barbaric way of preventing people with severe mental illness from harming either themselves or others.

Despite having been illegal since 1977, Indonesia’s Ministry of Health estimates there are currently 18,000 victims of pasung in the country. The Suryani Institute, however, puts that number at closer to 40,000, including at least 1,000 in Bali, where the easternmost cape, shunned by the majority of tourists and often ignored by the provincial government, remains a hotbed of poverty, substandard education and housing, poor health and inadequate policing.

Cokorda leads the way into a traditional Balinese residence where a woman lays offerings at a Hindu shrine adorned with stone gargoyles of local gods and demons. After mumbling a greeting, she points to a windowless concrete block, less than 10 square metres in size, standing in solitude at the far end of the garden.

Inside the block, behind an iron grill door, a frail old man is hunched naked on the floor. It is 32 degrees Celsius outside, and hotter inside, the walls smeared with faeces, the stench beyond belief. The only object inside is a bowl of water by the door, the kind one would give a dog. But while dogs receive daily exercise, this man has not left his cell in more than a year.

Despite the horrific confines, the man, who suffers from schizophrenia, appears to be in high spirits, grinning maniacally at his visitors. He mutters incoherently and can answer no questions, but tells us his name, Bagus, or, in the Indonesian language, “good”.

This is not the first time Cokorda and his team – Cokorda’s wife and Suryani photojournalist Rudi Waisnawa and his wife (who prefers not to be named) – have met Bagus.

Rudi pulls out his mobile phone to show a photo of Bagus from two years ago, when they found him in the same place with his ankles shackled in old-fashioned wooden stocks, Game of Thrones style. Rudi flicks to another photograph taken six months later: Bagus is well dressed, well fed, seated with a family member and looking intently into the camera – the result of antipsychotic injections that cost just US$4 a month.

“The last time we visited this man a year and a half ago he was in a much better condition,” says Cokorda. “He had responded well to the antipsychotic injections but his situation has now become worse because the family denied him further treatment. We had no idea they had locked him up again.”

The Centre for Sustainable Development Goals Studies at Padjadjaran University in Java has identified half a dozen key reasons why the practice of pasung persists in Indonesia, including poor under­standing of mental disorders, which can lead to a sufferer’s family being stigmatised. Often, deeply held religious beliefs mean that schizophrenia is understood as being the result of supernatural possession, and treatment is sought from shamans, traditional healers and village priests. When this fails, the disorder is considered an incurable curse.

But the most significant reason for the persistence of pasung is a lack of access to basic mental-health services. The World Health Organization estimates that 85 per cent of all patients with mental health disorders go untreated in developing countries, and Bali is a textbook example.

There is only one psychiatric hospital on this island of 4.2 million people, which for reasons unknown has the highest incidence of schizophrenia in Indonesia: 0.23 per cent, or 9,000 people, according to the Department of Anthropology at Bali’s Udayana University.

“Our national anthem says build the soul first then build the physical body second,” says Cokorda, standing outside Bagus’ cell under the hot afternoon sun, but the authorities, he says, “focus on physical health and forget about the mental health of our people”.

A 2017 review of Indonesian health care by the Asia Pacific Observatory on Health Systems and Policies, in New Delhi, India, corroborates the doctor’s claim. It found that Indonesia had just 700 psychiatric doctors to serve a population of 270 million – less than 3 per cent of the 24,000 the study recommends. Eight of the country’s 34 provinces have no psychiatric hospital and five do not have a single mental-health professional, despite such provisions being mandated by law.

In 2009, the government of Bali tried to turn things around by granting the Suryani Institute a US$500,000 annual budget. But the funding was removed the following year when members of parliament complained that too much money had been allocated to a non-governmental organisation.

Currently, the Suryani Institute runs on private donations and volunteers, the former having dipped in 2020 due to changing priorities during the Covid-19 pandemic and with the absence of Bali’s usual hordes of foreign tourists. The charity’s field activities have been significantly scaled back as a result and the team has not been able to check in on known pasung victims such as Bagus as often as they would have liked.

“According to our customs, the family’s wishes must be respected, so it’s a difficult situation,” says Cokorda. “That woman who let us in, she’s just a caretaker. My plan now is to call his family and ask permission to treat him again. If they agree I’ll ask the psychiatric hospital to admit him. If they don’t, the Suryani Institute will report this to the police.”

After being given these options, Bagus’ nephew and legal guardian, who last year made the decision to cease treatment, agrees to an intervention. Cokorda calls Dr Dewa Gede Basudewa, director of the Bangli Psychiatric Hospital, an hour to the northeast, in Bangli district, who promises to send an ambulance that same afternoon.

Given the state of mental-health care in the country, one might expect an asylum as underfunded and over­crowded as those discovered in Romania after the fall of the Iron Curtain. But the Bangli facility is modern and clean with numerous spacious wings, set in beautiful gardens and with a ward dedicated to treating patients with schizophrenia. Bangli has a budget to treat 50 pasung victims a year, but Gede acknowledges they are not treating a single victim at the time of our visit, and only one of about 30 beds is occupied.

Gede, sitting in his office on the top floor of the hospi­tal, puts this down to “stigma and marginalisation of mental-health disorders […] People in Bali are afraid to go to psychiatric hospitals because they think if their boss finds out they could lose their job, or they could be disowned by their family or communities. Many people think if you go to hospital you will come into contact with people infected with Covid-19 and cause an outbreak when you return home. This has led to a reduction in admissions of 25 per cent this year.”

The cost of travel to the Bangli Psychiatric Hospital, two hours’ drive from the capital and seven hours from the poverty-prone communities in west Bali, is a further disincentive to admission.

“Anyone who is mentally ill, rich or poor, we will admit them and do everything in our powers to help,” he says. “We care about our patients. They can stay here for up to six months for free, though the average stay is about two weeks. We treated one pasung victim who became a successful painter. When I saw him after he recovered, he offered me one of his paintings for free. But I insisted on paying. In fact, I bought two.”

However encouraging that may be, research by Udayana University shows the relapse rate of patients with mental dis­orders in Bali is 50 to 92 per cent, and Gede acknowl­edges only one-third of pasung patients are cured. “The other two-thirds relapse and are usually chained up by their families again, afraid they will become aggressive and hurt them,” he says, adding that some families even attempt euthanasia. “One patient who we treated for three years, when I asked his family to take him back home they said, ‘Either we kill him, or he kills us.’”

In Bagus’ compound, Cokorda sighs after listening to a retelling of Gede’s hospital tour, saying the patients there nearly always end up back in pasung situations because the institution is focused on treatment and rehabilitation, not permanent care.

“The hospital and the politicians who fund it forget the patient needs to go back to the community and deal with their family and daily activities,” says Cokorda. “The patients relapse and become aggressive, the families feel hopeless so they chain them up again. We’ve offered to help create an integrated treatment plan that works in conjunction with local health clinics, empowers families to prevent patients from relapsing, but nothing ever changes.”

The ambulance arrives more than three hours later, but Bagus’ ordeal is not yet over – the house-sitter, appointed by Bagus’ nephew to guard his uncle, has lost the key to his cell. Thus begins a procession of neighbours arriving with increasingly formidable tools to break the padlock.

Eventually they succeed but the door will not budge; the hinges have rusted to the frame during Bagus’ year-long confinement. Another hour passes before he is finally freed, the muscles in his legs so atrophied that he cannot stand up on his own and must be carried by neighbours to the ambulance.

This check-up turned rescue mission has been successful: Bagus will have his first hot meal – and bath – in more than a year. But no one on Cokorda’s team is looking any happier for the achievement.

“Yes, he will sleep well tonight,” says the doctor, “and they will give him medication to make him feel normal again. But eventually he is going to have to be discharged from the hospital and if they send him back here without any kind of plan to help his family and the community to care for him, we know what the result will be.”

Ideally, formally aggressive mental-health patients whose families still fear them would be placed in a halfway house after being discharged. And while there are no state-run halfway houses in Bali, there are other non-profit organisations, such as Yayasan Solemen Indonesia, that are trying to fill the gap.

Over the past decade, Solemen has rescued 42 pasung victims, including a man who was kept in a cell for more than 20 years. Much to their credit, Solemen’s volunteers and full-time staff have fully rehabilitated about three-quarters of these former sufferers.

“Once they are released from hospital, our psychia­trist continues to visit them every two or four weeks to administer antipsychotic medication and to give food parcels to the family,” says Sarah Chapman, a Solemen co-founder from Britain. “We don’t just open the door or break their chains, we continue to monitor, rehabilitate and reintegrate them into general society. We teach the family how to care for them and how to watch out for relapse signs.”

And while it is often possible for Solemen to pick up where Suryani’s work ends, the fix is never quick or cheap. “We’re still caring for pasung victims we met seven or eight years ago. Our motto is once under our care, always under our care,” Chapman says. “Some have been chained up again because they’re just too aggressive and their families are very scared of them. But our objective is to re-release and rehabilitate them as soon as it’s safe to do so.”

When the ambulance finally leaves, patient on board, Cokorda and his team resume their mission of mercy in east Bali; there are two more known pasung victims they are scheduled to visit in the area today, and the second lives less than five minutes’ drive from Bagus’ recently evacuated cell.

Kadek is in her mid-20s, with a mane of silky jet-black hair and pixie-like features to match her voice. The team find her sitting on a veranda chatting with her family, preparing offerings for their compound’s communal Hindu shrine. But things were not always so rosy.

“When I first met her, three years ago, she looked like this,” says Rudi, showing a photo of Kadek on his phone, her hair a mess, face contorted in pain, lying on the ground in a terribly twisted position, calves raised on a concrete bench, ankles shackled. Unlike Bagus’ wooden stocks, hers were made of iron.

“Every time I see people in pasung it breaks my heart but I keep on coming back,” says Rudi. “I dedicate my time to the Suryani Institute because I think I can help people by creating empathy with my photos and documentaries. I speak at universities and have hosted exhibitions of my photos overseas.”

After two years of treatment with antipsychotic injections, Kadek had recovered to the point where she was able to marry and move to her husband’s home in Singaraja, the second largest city in Bali, on the little-visited north coast. But Kadek had no access to antipsychotic medication there and things quickly went bad. “I started hearing voices in my head again and seeing hallucinations while praying,” she says. “My body started overheating and I understood it as a sign that I was about to relapse.”

A few months ago, Kadek’s husband divorced her and sent her back to her parents’ home, where she is again receiving regular visits – and antipsychotic injections – from the Suryani Institute. “After the doctor gives me his injections, I feel calm and I can work again, make offerings at the temple and participate in Hindu ceremonies,” she says.

Kadek’s father looks at his daughter lovingly and strokes her hair; it is hard to fathom how this gentle old man with a fixed smile and intelligent gaze could be capable of such cruelty and neglect.

“I was very angry with my father,” says Kadek, who is too scared to return to the room where she was shackled for weeks on end for more than a year. “I thought, ‘Why does he treat me this way? This is not me. An evil spirit has possessed me.’ I wanted to be free and my feet hurt in the restraints. But now I know he did it because he had no other way to stop me walking into our neighbour’s home and disturbing them.”

“I tried everything,” says her father. “I took her to the psychiatric hospital in Bangli. She stayed there for eight days but when there was no change in her condition, they sent her to a general hospital in Denpasar. But they couldn’t do anything and discharged her. I then tried a traditional healer and I paid a high priest lots of money for a water purification ceremony. But again, nothing changed and when she returned home, she caused trouble with our neighbours again. I had no choice but to lock her up.

“My intention was to help her, not to hurt her, and I never kept her in the stocks for longer than one month because my wife complained it was too hard to wash her. Now that she’s getting injections, she is normal and calm. Will I lock her up again? Never. Dr Cokorda has taught us it does not help her situation.”

After giving Kadek her monthly injection, Cokorda and his team set off to see their third and final patient of the day. The route takes them along a dirt track edged with banana trees that becomes narrower as it ascends inland into the hinterland of eastern Bali. Soon they must park and continue on foot until they reach a lonely little hamlet, frozen in time, yet to be connected to the electricity grid.

A gate surrounds a spartan wooden farmhouse whose residents live in conditions on par with the worst slums of India. The owner, a man in his 50s with two large buck teeth, is a pigeon breeder. The birds’ feathers and droppings carpet the ground.

The commotion causes a dozing octogenarian to stir and wake on his wooden bench. His face is so deformed by age and hardship that his cheeks and lips dangle like deflated tyres near his chin. His wife then emerges from the house. Both are blind with cataracts clouding their eyes, clothes beyond filthy, hanging on by threads, and not a single tooth between them.

The team has come to treat a schizophrenic who spent six years shackled in a barn after nearly beating his father to death with a stick. But they are told the sixty-something-year-old died a few months ago, apparently from a stroke. No one in the team expresses any emotion after learning of the man’s death.

“People think Bali is full of money and five-star hotels,” says Cokorda. “But in reality, it’s still like this.”

Some of the names have been changed.