The Indonesian government is challenged by an ever increasing population, a reluctance of physicians to practice in remote areas, and a lack of funds to modernize existing facilities or to build new medical facilities. As a result, the government hospitals are overcrowded, terrifying places, where families are at the mercy of the staff, and from which patients beg to come home. While the hospital is not necessarily seen as a remnant of colonial domination, it is still an institution foreign to Javanese culture, and every attempt is made on the part of the families of the patients and (and sometimes staff) to allow for elements that make care in the hospital more culturally acceptable. Lower-class families cowed by the educated and imperious staff receive little information about the prognosis of their patient, but can busy themselves with helping keep their patient clean, calm and well fed, and with prayer: there are good-sized mosques at every government hospital and Christian chapels at some.
Although family members with the resources can request a private (non intensive care) room with an extra bed for a family member, and can also choose to receive hospital meals, people will bring cooked food and snacks from home for the patient and their visitors. Outdoor open-air pavilions house the families of patients who do not have private rooms, but with untold people sleeping on mats one next to the other, using scant public bathrooms, and visiting patients with communicable diseases freely and with no attempt to control contagion, sanitation is suspect; conditions seem chaotic; and despair is seen on many faces. Even in the birthing wards, the most cheerful area of any hospital, in the "baby seasons" that follow like clockwork nine months after the two months of the Javanese year deemed particularly auspicious for weddings, beds are placed so closely together that they touch, and sometimes women are two to a bed.
The perception exists that while people do not die from treatment by a dukun or a kyai, people can be killed by the treatment they receive from the doctors and nurses at the hospital. The fact that the patients are brought in in extremis, as a last resort, does nothing to dispel this perception.
The mental hospitals inspire their own form of horror: a fundamental fear of human beings who have lost the control of themselves that defines them as human in Javanese culture. The government mental hospitals face even greater funding constraints than the general hospitals, and despite very dedicated doctors, often staff are poorly trained and spread too thinly. These institutions are for the violent, the psychotic, those the families can no longer handle without tying them up or locking them in a shed or a bamboo cage. The option for free treatment for the impoverished inspires many families to bring in their patients; the shame that a mentally ill family member brings to a fami1y also helps the institution become a viable option. The private mental hospitals, like private general or birthing hospitals, have a much more pleasant environment and cater to patients who check themselves in by choice, to partake in a kind of rest cure, but the truly economically and emotionally desperate usually end up housed in the government mental hospitals, helpless and hopeless.
development of a formal health care system in Indonesia
In 1621 the Verenigde Oost-Indische Compagnie (imitating the British, the Dutch East Indies Company, commonly known as the VOC, or just "the Company"), built a fortress in Batavia (in the area of what is now Jakarta) as the local station for their lucrative trade between the Netherlands and the islands of Indonesia then known as the East Indies.1 In 1626 they built the first hospital near the fort, to help heal the sick and wounded sailors and traders, in order that they could more quickly return to making money for the VOC (Sciortino 1996:24-25).
More hospitals eventually followed: in 1648 a small hospital was founded on the island of Ambon; in 1715 a small hospital was established on the island of Sulawesi at Makasar; another near the original fort in 1779; and a military hospital at Weltevreden in 1800. Small medical posts were set up over the same time period, scattered over the Dutch trade areas in the Indonesian archipelago on the island of Sumatra, in the Spice Islands and the Moluccas (Schoute 1937 quoted in Sciortino 1996:25). The VOC went bankrupt and was formally dissolved in 1800, and its territorial possessions-including infrastructure and trade networks in Indonesia - became the property of the Dutch government. Many of the small medical posts closed, and the hospitals that were kept open "stagnated and deteriorated" (Schoute 1937 quoted in Sciortino 1996:27).
During the whole of the 19th century, medical care in what was then the Dutch East Indies was run by the military medical service, and was aimed at maintaining the health of armies, the civil administration, traders and planters, with little concern for the indigenous population (with the exception of the period of 1811-1816 when the-English briefly ruled the area). There were very few medical officers for such a large area: no more than 130-160 stationed there (mostly in Java) on the average over the 19th century (van Heteren 1996: 8). Although many of the medical officers only had honorary medical degrees, they gained important medical knowledge in the areas of epidemiology, parasitology, and bacteriology-especially with reference to tropical diseases such as typhoid, dysentery, cholera, malaria, and hookworm. While working to keep the troops healthy, they performed research into nutrition and vitamins, hygiene and public health.3 In 1820 the military underwent a major reorganization, and with the medical system under new management, a couple of new institutions were set up to serve the non military European poor and the' indigenous population, but they quickly became "neglected shelters for all kinds of marginal people, such as prostitutes, prisoners, the mentally ill, and mendicants" (Sciortino 1996:29).
The Dutch did however relatively little in the field of public health in Indonesia prior to 1910, with the exception of giving smallpox vaccinations. Public health policy was non-existent under the colonial administration, except for a vaccination campaign in the early 1900s (Connor 1982:50). However, the obvious need for more medical aid led to the call for indigenous medical help, which led the Dutch chief medical officer in 1851 to open the Dokter Djawaschool for Javanese noble-class men who could read and write Malay (cf. de Moulin 1989: 27), with the intention that they would learn some medical skills, and return to their area of origin to practice on their fellow Javanese, and 50 Javanese gentry were trained as doctors and nurses to serve the urban and village sick. In the 1890s, the official recognition of the natives as an important factor in economic development caused a shift in the focus of the training of the indigenous doctors (Worboys 1989: 153-155). Soon the school was reorganized and additional tutelage in the. natural sciences, including anatomy and physiology (which required the dissection of corpses), physics, geology, and hygiene was offered, and an extended clinical residency was required in which students practiced pathology, surgery, and wound dressing. In 1899 the school was renamed School Tot Opleiding van lndische Artsen (known as STOVIA, Training School for Indian Physicians).
In 1901 in Indonesia there was one doctor per 560,000 inhabitants, while in Europe the average ratio was one doctor for every 2000 people (Sciortino' 1996:35). Despite the fact that the Western system of medicine was not totally accepted by the indigenous Indonesians (in fact they were suspicious of the motives for the inoculations, and found the hospitals to be quite unpleasantly foreign), political thinking in the Netherlands started to produce new colonial policies that centered on the idea of the moral duty of the colonists to improve the life of the colonized-the so-called "ethical policy" -instituted in 1901.This policy led them to consider it no longer justifiable to reserve medical treatment for the wealthy few, or treat people only during epidemics. So a flurry of building ensued, with new hospitals built in major urban centers, and old hospitals refurbished (Sciortino 1996:32-43).
In 1925 then Public Health Service was formed; and the health system was decentralized, placing responsibility for running the health centers with local, lower, administrations in provinces, regencies and districts (Sciortino 1996:42). And a more elaborate public health care infrastructure developed by 1939, but this public health system collapsed after the Japanese invasion in 1942. The Japanese colonized Indonesia from March of 1942 to August of 1945. All over the archipelago, large buildings like schools and hospitals were taken over and used by the Japanese. During World War Two, mortality rose dramatically and the general health situation of the country deteriorated (Frederick and Worden 1993:131). In the postwar period, a network of community health centers was established, but resources were still extremely limited. The network of medical institutions in Indonesia followed the Dutch colonial economic development: hospitals were set up in major urban areas only. In the 1950s and 1960s, birthing hospitals, anti-smallpox campaigns and other public health programs were developed. In the 1970s, many community health centers (Pusat Kesehatan Masyarakilt) were set up to help provide the low-cost, basic primary health care that was required by World Health Organization policy of that era (Connor: 1982:51). These puskesmas, as they are known, helped decentralize medical care, but rarely were any of them staffed by a psychiatrist.
Despite the fact that direct central government spending on health fell by 45 percent between 1982 and 1987 because of declining revenues from the oil industry (Frederick and Worden 1993:132), and that the country has been hard hit in the economic sector due to political upheaval, natural disasters, and the Asian monetary crisis of the 1990s, health in Indonesia has shown improvement: life expectancies have risen almost ten years since the 1970s, and infant mortality has declined (Frederick and Worden 1993:129; WHO Country Health Profile-Indonesia 2003). Health insurance is becoming increasingly common: a 1992 law required all employers with more than ten employees to provide health insurance; free health care for government employees has set the standard for corporate employers, who now generally provide a health insurance benefit for their employees; and factories have on site private clinics. But the actual infrastructure has not been greatly enhanced; the Indonesian government has continued the Dutch colonial pattern of low investment in health care, not spending even as much as other Southeast Asian nations on supporting the health care system. The rural poor, especially those on islands other than Java, have much less access to cosmopolitan health care than their urban neighbors, and the ratio of hospital beds of 0.06 per 1000 population hasn't changed since the late 1980s and continues to be the lowest among Southeast Asian nations (Frederick and Worden 1993:129; WHO Country Health Profile-Indonesia 2003). In the following table we can see some of the pertinent health statistics for Indonesia culled from the most recent sources available: 1998 statistics from the Indonesian Ministry of Health Center for Health Data, Indonesia HealtProfile 1999 Jakarta, February 2000, and from the World Health Organization Country Health Profile-Indonesia. Although comparing statistics from a developing nation with a developed nation may have little instructive value, it serves to demonstrate the vast differences in resources that can be brought to bear in the health sector, and the concomitant effects on the health. of a population.
It is very difficult to get accurate statistics in Indonesia since there exists a universal practice of fixing the statistics at a local level to conform to central government policy and goals. My students who chose health care as a research topic in Java, Bali, Sulawesi, and Madura regularly were offered or were shown when asked two sets of books that local clinics or birthing centers kept - one that listed the actual patients seen and medications dispensed, or the other that indicated compliance with national goals. This common practice is what Sciortino describes as 1/ a socially accepted way of handling a situation wherein the health workers are unable to deal with all the tasks they are called upon to perform by a health policy defined according to international and national ideals, a policy which does not take into account the actual capacity of the health center and its staff" (Sciortino 1995:147). This makes it very difficult to extract accurate information, but nonetheless the general situation is obvious.
Government and private health care facilities, like many of the other resources in Indonesia, are most readily available and most developed in Java. The outer islands still continue to suffer a severe shortage of physicians and hospitals, despite the fact that they are the places often most hard hit by natural disasters, economic crises, political or ethnic conflict, and are all deeply impoverished.
In 1961 the first private mental hospital opened in Jakarta, followed by others (three more in Jakarta by 1971, and other private facilities in Yogjakarta and Surabaya in Java, and in Medan in Sumatra). These facilities, and the developing health department, began to focus on preventative measures, rehabilitation and paramedic education, rather than simply control of aggressive, impulsive and destructive" patients (Setyonegoro 1976a:83).They began work that included university researchers, mental health workers, and communities surrounding the mental hospitals, which was intended to help develop society's understanding and acceptance of mental illness. In 1966 then a major law was passed which legislated funding for the Directorat Kesehatan Jiwa, and established sub-directorates for promotion, prevention, service and curing, rehabilitation, research and data collection, and a position of the head of administration that would handle personnel, budgets, planning and supplies (Setyonegoro 1976a:84-85, 1976b:20-21). It explicitly identified problems of industrialization, urbanization and modem technology to be addressed by this directorate, along with other problems such as juvenile delinquency, mental retardation, narcotic addiction, individual or group panic, and mob violence (Setyonegoro 1976b:21; Maramis 1998:17-18).
In 1971 when Setyonegoro took over the directorship of the department of mental health, other new laws were instituted, which stated that if a psychotic individual was brought to or picked up by the police, the police were required to bring the patient to the mental hospital, and the cost of their treatment would be paid by the Dinas Social DK Jaya (a social welfare agency). The Badan Koordinasi Rehabilitasi Penderita Patien Jiwa (Coordinating Agency for the Rehabilitation of Mental Patients) was formed to come up with ways to speed up the return of mental patients to their homes, to help find them jobs where they would be „ free or protected", and to determine how the institutions could follow up on released mental patients. This group included members from the departments of Social (Welfare), Labor, Transmigration, Industry, and members of the faculty of psychiatry from the University of Indonesia (Setyonegoro 1976b:10-11). By 1975 there were 40 psychiatrists and about 60 general doctors, some of whom were continuing their education at medical schools in Jakarta and Surabaya for psychiatry (Setyonegoro 1976a:87). The function of the mental hospitals underwent a change, from the Dutch model of simply custodial care to developing in the areas of mental health promotion, vocational rehabilitation, and "psychopharmaceutical, psychosocial, and psycho-cultural research" (Setyonegoro 1976a:89). In 1974 the directorate started work to integrate the puskesmas local health clinics into the mental health services system, and published the first edition of the Buku .Pedoman Kesehatan Jiwa Untuk Puskesmas (Manual for Mental Health for the Puskesmas) a kind of basic manual for identifying and treating the mentally ill for the doctors, nurses and social workers that staffed these small local health centers. The puskesmas staff were still, and continue to be, encouraged to consider themselves a back-up or resource facility, and to send any emergency cases of / adolescent crisis, family crises, psychotic episodes or suicide attempts, rapes, extreme anxiety or any other condition that requires a psychiatrist" to the nearest formal mental health facility, which had grown to include a mental health section of the Army hospital(s), and the private mental hospitals and clinics (Setyonegoro 1976a:92).
In an attempt to ensure consistent and uniform diagnoses, the Directorat held a Seminar Kesehatan Nasional (national health seminar) in 1973 to discuss diagnostic categories and methods of diagnosis, and the results of this seminar were sent to mental health facilities and educational institutions all over Indonesia. This developed into a Buku Pedoman Gangguan Jiwa Indonesia (Guide to Mental Illnesses in Indonesia) which was published in 1975 and continues to be used today, in an attempt to systematize and unify diagnosis and treatment country-wide (Setyonegoro 1976b:15). Various projects have been instituted to collect statistics on the epidemiology of mental illness, and to evaluate the efficacy of various facilities. Some of the more interesting of these projects were research into the social background of outpatients in Java and Bali, research into the marital conflicts that result in divorce in Medan, and the effects of tourism on the mental health of the Balinese (Setyonegoro 1976b:15-19). The development of anti-anxiety medications, anti-depressants and anti psychotic medications that began in the 1950s instigated a collaboration among psychiatrists, psychopharmacologists and biochemists, in an effort to treat patients more effectively and more humanely. However, the "Electro convulsion Apparatus" was still considered. vital to treat some patients (Setyonegoro1976a:94-95). The goal became not just to contain the patients someplace where they' would not present a danger to themselves or otherbut to "send them home as quickly as possible so that they could return to being an active part of society's activities"; the statistics showed that approximately 40 percent of mental patients in government hospitals were staying there more than a year (Setyonegoro 1976b:13).
In the 1990s the Indonesian government developed various programs and projects designed' to expand coverage of the mental health services and develop and revitalize mental health services and facilities. This undertaking can be seen from the example of one educational program that delivered training for personnel from 661 health centers, 437 general hospitals, and almost 5000 various seminars or activities designed to provide guidance to health workers on how best to deal with the mentally ill (Setiawan 1999/2001:6-7). A 1992 law defining mental health (Setiawan undated paper circa 1999:1) outlined the decentralization of the administration of mental health services, causing concern that the mental hospitals will be forced to provide more general health services in an attempt to help generate revenue for the area government services, according to psychiatrist Dr. Aminullah, the head of the Union of Indonesian Mental Hospitals (quoted in Dahuri 2002:1).
By 2006 when we did this research, there were 34 government mental hospitals (including one hospital for drug dependence) in 24 provinces out of the 30 provinces of Indonesia, and less than 30 small private mental hospitals. Huge provinces that still do not have mental hospitals are Central Kalimantan (Borneo), East Nusa Tenggara (the many islands east of Bali), and East Timor. Out of 806 general hospitals, 50% or 403 have mental health professionals working there (Setiawan 1999/2001:4). Out of nearly 20,000 community health centers across the archipelago, only about 10% or 1852 health centers have any kind of mental health professional available to consult with them on a regular basis, or associated with them (Setiawan 1999/2001:4). Community health centers (puskesmas), with a physician as titular head but in effect run by nurses, will refer psychiatric patients to the nearest government hospital, where they might find a bed. The bed occupancy rate averages 90% in government hospitals and 50% in private hospitals. However the patients in the state mental hospital have no privacy, no entertainment, just three concrete walls and a wall of bars that closes them in and opens them up for scrutiny to whoever chooses to stare at them. The well-groomed expansive grounds look peaceful and welcoming to the Western eye (once one gets past the guard posts and the gates), but visitors are few and far between, and maybe it is just that openness that creates in the Javanese a sense of eerie aloneness or abandonment. Tiny barred windows face the parking lots and the green expanses which surround the buildings; pristinely painted buildings echo the Dutch colonial influence, and in some cases actually are converted military or government buildings built in colonial times. Mental hospitals have a completely different feel from the hospitals that typically treat the physically ill: there home is brought to the patient in the hospital. Entire families camp out near the room of the patient or in the special family pavilions while they gather on their rattan mats, cook their familiar food, and keep their vigil.
Patients are fed and bathed by their own family members, with food, clothing and bedding brought from their own home, and concern about disease vectors and community opinion seem to be non-existent. The patient with no family to visit her or him, no one to sleep in the bed next to them, are very much pitied, but even here the mental wards are fenced no-man's-lands that are carefully avoided. Families of physically ill patients are anxious to bring their loved ones home as soon as possible, but families of the mentally ill seem only, 'too glad to be rid of them. They are the willfully forgotten ones. Over a number of years I collected about fifty articles from local and national newspapers pleading for citizens to bring out their mad, to take their confused, catatonic, or caterwauling family members to the state mental hospitals for free treatment rather than locking them up ,in stocks. The shame, the horror, the potential impact on mate selection and job possibilities and any kind of acceptance in the community for their (other) children make the families desperate to hide the stigma of madness. If the "bobot, bibit, bebet" of a potential mate for a son or a daughter, includes the existence of mental illness or other inheritable diseases in the family I a marriage is out of the question.
Madness in the family effectively negates the social future of a Javanese. The state mental institutions "work" for the community and the family of the patient, in that they restore order to the community; they remove a blight from the family's existence; they erase a blot of shame from the family rolls (in fact the family no longer even has to list the institutionalized mentally ill on the government census card that lists the members of their household); they eradicate a painful nuisance from the family compound; and they negate the possibility of exposure of a shameful family secret. But do they work for the patient? I suppose being locked up with others like yourself and receiving some medicine on a regular basis has something to be said for it, especially if the alternative is being constantly alone and bound' hand or foot. The prognosis for these patients is not good but it seems that the curing of these patients is not the point - control of the patients and a return of calm to their community seems to be the priority in most cases. In the large government mental institutions in Java they struggle with trying to get people to bring out their mad, and trying to house them in as clean and comfortable, as orderly, and yes, as secretive surroundings as is possible with the resources the central government has allotted them. It is a hard and thankless job that the doctors and other staff do at these state mental hospitals, but it is a harder and even more hopeless place for the patients.
A distinguished psychiatrist and director of the very humane Rumah Sakit Wikarta Mandala mental hospital in Pujon, just outside of Malang (Java), described the function of paternalism within his relationships with patients and their families, and within his institution: For the person who is sick, we want to work on awareness, to make the patient aware of themselves and the world around them, the microcosm and the macrocosm. We do various therapies to help them get back in touch with reality. In order to develop this, to socialize patients, we use drugs, learning therapy, behavior modification -now those are all very typical. But we don't just use psychotherapeutic counseling, or Freudian psychotherapy, because Indonesians are not satisfied if we come to a counselor asking for help and we are just asked to talk... we don't want to say anything. The strategy that we use is that we have to instruct them: ok, this is what you have said, this is what your problem is, and this is what you have to do. If we give them non-directive measures, they don't understand why they are just ordered to tell a story, we have to give them instructions about how to behave and solve their problems, and that satisfies the Indonesian client. .. The nurses are also encouraged to develop their potential, so that we can trust them and be certain of their ability to deal with patients on a one-to-one basis in a way that is like family, like sisters and brothers, just as the doctors are very much like parents. The patients are treated with respect, so that they do not have to be restrained or tied up or isolated, which we do not practice. We train our nurses so that they do not have to be afraid of the patients, and can treat them with respect, and know that they can control them without restraints, with just their own knowledge and ability. We are confident enough to deal with the patients as family; we guard the hierarchical relationship within the idea of the family. We-doctors, patients and nurses-guard the feeling of family. This works well in Indonesia because the power and ideology (of family), the pattern of paternalism is very strong here in Indonesia.
In fact the tone of the communication a physician or psychiatrist selects to address his or her clients and their families depends on two things: the setting, and the social class of the client., Limited time and an unending stream of patients emands rapid treatment and quick consultations with nurses or doctors on duty. Thus even desperately depressed and anxious patient is dismissed after about three minutes of questions, and the family was simply told to take them elsewhere, as the puskesmas facilities were,inadequate. Physicians speak the egalitarian Bahasa Indonesia, with sprinklings of English and Eriglish medical terms, but some will speak Javanese with their patients, especially the elderly ones, and principally when important information is being expressed and the doctor wants to avoid misunderstanding.
It is nor surprising therefore that Indonesian psychiatrists express frustration with the nearly overwhelming forces of globalization, modernization, social pressures and changes that they bring to a rapidly changing, and stressed, population. For a patient diagnosed with psychotic behavior, Browne found that the consultation is relatively brief, usually five to ten minutes. For patients suffering from anxiety and depression, on the average the sessions are a bit longer, the patients are encouraged to talk more, and "sometimes a little psychotherapy is provided'(Browne 1999:216).Sessions at the psychiatrists'- private practices are much longer, but still focused on very practical questions, inquiries less about how the patients were feeling than about how well they were -managing to control their anti-social behaviors. - Physical examination of patients presenting emotional distress is minimal, and the only medical instruments are occasional use of the stethoscope or he blood pressure gauge.
As we have seen this is distinctly different from curing sessions with the kyai or the dukun. Like Sciortino's descriptions of clinical encounters with nurses at the puskesmas, the patient of the psychiatrist asks no questions, requires no interpretation of symptoms, and is given very little information - they simply place their trust in the modem medical knowledge and medicine mastered by the psychiatrist. But under the unquestioned authority of the psychiatrist, Western medical theories and medicine also, become sacred, or at least sacrosanct; all the rest of their treatment is unrelentingly secular, with the exception of the religious therapy offered at Dr. Soeyono's hospital, designed to make Western psychiatric treatment culturally acceptable to the Indonesian client and their family. Thus at the exemplary Rumah Saklt Wikarta Mandala in Pujon (pointing to a direction for other Indonesian institutions to devellop into), all patients are expected to join in group therapy every day of the week. Occasionally dispensation is granted by the doctor, when requested by the patient, to be excused from therapy for one or more days. The therapy includes music therapy (singing individually and reading patient poetry with a band of two electric guitars and a drum set, and singing and dancing as a group), dance therapy (classic Indonesian as well as Western disco), group discussion, sports (including hikes, swimming, volleyball), crafts (such as sewing and sculpting) and cleaning therapy. (where the patients are supervised and given lessons in how and why to keep themselves, their personal areas, and the hospital grounds clean and neat). In the drama therapy, small plays are memorized and performed from scripts written by the staff social worker and therapists, scripts that serve as moral and practical object lessons in social conduct for the patients. The patients are engaged in role-play with the therapists to reinforce or relearn social integration. Various kinds of therapy encourage appropriate integration into social structure; performing in scripts featuring typical situations, patients are taught or retaught how to respond in a socially acceptable manner, that is how to have social intercourse in a way, the Javanese way, that never challenges the status quo, that is designed to maintain rukun with their family and community. Opportunities to observe and practice Javanese rules of etiquette -tata krama and sopan santun-are modeled and patients were coached in appropriate response to Javanese cues about hierarchy and social distance.But they are also given the opportunity to practice religious meditation of any kind, and are coached, if they have reached an appropriate state of awareness, in Javanese kebatinan practice.
As we have seen in general people are admitted to the mental institution by families who could not control their violent behavior, or felt they were victims of demonic possession, or admitted themselves for help with uncontrollable. stress. While they were given medication, as far as we could determine there was no institutional labeling of an individual's condition, no focus on development or expression of self, or resolution of internal conflict, obsession or grief. If they were at an institution that actually performed regular, organized therapy with their patients, most were treated to an exploration of problems of assimilation. Patients were involved in integrative group therapy, focused on resocialization,-and the provision of a space in which the individual can rest away from the society that so stigmatizes their condition. The physician's literature reflects this difference in the Indonesian style of treatment, with several doctors writing on the necessity of putting the person back in balance,and returning him to a harmonious relationship with the others around them. The problem of mental illness, as Indonesian psychiatrists see it, is not disorder of the individual personality (although they use the term), but disorder within the particular brain chemistry or social situation or spiritual condition (ie spirit possession) of that individual. The majority of psychiatrists in Java are unwilling or unable to adress the socio economic factors and that may hasten the onset of mental illness, and limit themselves to providing for their patients perscriptions that presumably will help balance their brain chemistry. They don't have the time or training to give patients much more than medicine. As a couple of doctors admitted, the rest is best left to psychologists. This is a subtle but very telling difference in the way Western psychiatric principles are interpreted, and the best example of the way culture influences the clinical practice of most Indonesian psychiatrists.
Conclusion: What we have seen in the first parst of this investigation is that traditional medicine is still robust part of the health-seeking process in Indonesia, but may not produce universal, permanent cures. The cost of seeing a dukun or a kyai can vary but it is necessarily cheap although he kyai is the cheapest of all options. For the social scientist however, it is difficult to obtain statistical information on the rates of paths of resort today in Java, other than to determine that traditional medicine is still a valid option. In fact many people today are embarrassed to confess their resort to kyai or dukun.Yet the Javanese feel that the dukun and the kyai are somehow more altruistic than the doctors. Undeniably, they see a visit to a doctor will engender a quick fix for many kinds of purely physical simple ailments, but for the more complicated symptoms of mental illness, the dukun or the kyai are the curers of choice for many Javanese.
Sciortino came to the same conclusion: "In general it can be said that when they desire quick results they use one of the many public and private biomedical options... But when they desire a treatment that truly eliminates the causes of disease and does not merely suppress its symptoms, they prefer traditional remedies" (1995:237). The temporary state of shock and the symptoms of mental illness as it is culturally constructed in" Java are often relieved by a visit with a kyai or a dukun, who help the sufferer return to a "stable state of self-control, reclaim their personal and social equilibrium, regain acceptance of fate or 'God's will', as it reaffirm their religious or philosophical perspective.
Cures as socio-cultural constructions of identity
People are simultaneously affected by all kinds of influences because they are at once subject to social, cosmic and material forces. Each kind of influence on a person is partial. None is considered by villagers to account for all illnesses. D1nesses must be explained so that an appropriate remedy can. be found... Explanations of illness are linked, explicitly, to therapeutic choices. But these explanations have implications that extend beyond healing as well. The actions people take to understand and cure illriess also assert visions of a social world. Explanations of illness refer not simply to 'what happened' to an afflicted person but serve, as well, to delineate a person's place in specific social relations.-Stacy Pigg, Disenchanting shamans: Representations of modernity and the transformation of healing in Nepal, 1990:262-274.
Indeed we have seen that the cultural values that the Javanese have learned as children, the values expressed in their home and neighborhood, their ethnic and religious identity and affiliation, all affect the interpretation of symptoms and the paths of resort to a curer. Javanese feel responsible for one another; family ties and social obligations are extremely important since there is no national welfare system in place.Through primarily private religious' institutions like mosques, orphanages, pesantren religious boarding schools and public schools, Javanese support the destitute and give generously, and directly, to those worse off than themselves. The philosophy and. practice of gotong royong (mutual help) and musyawarah (consensus decision~making), cause the network of social relations and the ethics of civil society to be quite strong. As Javanese are involved in the community, so is the community often involved in the lives of each Javanese family. The poorer the. neighborhood, the more likely it is to be ethnically, religiously and econonUcally homogenous, and the more likely it becomes that family decision-making will be strongly influenced by' community opinion. Thus for the Javanese, socio-cultural status often defines what kind of curer they will go to first, and the type and level of symptoms will determine if the patient ever sees the inside of a psychiatric hospital. The community may insist that their local elected leader, the RT or the RW may intervene and institute the instruments of social control if the symptoms of mental illness are violent or disturbing enough that community rukun is repeatedly violated. At that point the decision is effectively made for the family, when the agent of disorder is removed to an institution. This path of resort is in many cases, a path of last resort, simply resorting to storage and containment of the disturbed individual with little or no hope for a cure.
While illness clearly has an important semantic component (symptoms are culturally constructed in meaningful ways) and clinical interaction has an interpretive dimension (e.g., physicians fit self reported patient symptoms into a clinically meaningful diagnosis) it is necessary to analyze these processes in terms of the role of culture in sustaining power and privilege. -Merrill Singer and Hans Baer, Critical Medical Anthropology, 1995:269
While individual class and ethnic identity are unchanging markers, social status is context dependent. It can vary according to the class, age, gender, kinship relation, education or position of power of the individual with whom a Javanese relates. The language that one uses, the body posture, the gestures-indeed whether or not another might even be addressed-is dependent on the politics of identity, whom the Javanese must become in each encounter to conform to the unwritten laws of social relations. For the Javanese, their social identity is a major determinant of the paths of resort for medical treatment that they will pursue. This is not as simple as identifying as villager or urbanite, as a Muslim or non-Muslim, as a member of a particular gender or ethnic group. They have something to do with economics and education, but these are not the only determinants of difference. Very real social differences lie in the quality of their religious beliefs and practices, the nexus of custom and belief that is praxis. Different kinds of curers are associated with these degrees of social difference, and the varieties of the curers' beliefs and practices reflect the varieties of power recognized by the Javanese - religious power, supranatural power, and institutional/ governmental power or the power of position. Unlike other studies which suggest that increased education, rise in income and/ or ascending social status reduce the level of belief in mystical, magical or supernatural stuff, everyone in Java would agree that there is a level of our world, or a world that coexists. with the world of our perceptions that is beyond normal comprehension or even apprehension. However, the cosmology of their mystical world will differ depending on the level of their commitment to, internalization of and interpretation of Islam. And the likelihood that they will choose a particular kind of curer will be tied not to their educational or economic situation, but instead be often tied to their network of social relations. In Java, the modem has not yet edged out the traditional. For example, in many countries, as Pigg found in Nepal, urbanites have problems accepting ghosts and spirits (pigg 1990:452) but not in Java. Traditional Javanese ritual and fundamental Islamic belief are a large part of even the largest cities in Indonesia. In East Java Islam seems to have taken the strongest hold on the population, and more people are actually pious, practicing Muslims than elsewhere in Java, but the Islam with its Sufistic mystical flavor, makes the kind of meditation, trance and ascetic exercises practiced by the dukun perfectly understandable, and makes the existence of kyai who have developed powers through participation in similar practices virtually guaranteed.
The psychiatrist possesses the power of the ' moderen', of science, of the institution; is much more likely to be of a different social class and ethnicity from his client; and is the only curer whom the government would not question if he confined his patient. The kyai possesses the ability to channel the power of God. And the dukun with their paranormal powers, like the shaman described by Levi-Strauss, "provides language" (1967:198) and promotes reintegration for the patient, allowing mind, body, individual self and society the chance to express their shared symbolic system. The individual East Javanese will not consider each of these types of power as equal, equally valid, or equally strong. Geertz's characterization of the Javanese health-seeking process as "flailing" is mistaken: even if they are desperate, Javanese will not grab at any straw. For the lower socio-economic classes, hospitals are still where you go to die; they do not believe in the power of science to diagnose or cure the extremely ill, but they won't all go to just any kind of a traditional healer. However, how people choose to treat mental illness depends on how they define and diagnose the symptoms, and on the social milieu in which they live. When determining the potential efficacy of any kind of cure, all. will depend on if the curer cocoks-fits--with the individual patient, and for now the continuity of Javanese culture is still there.