Hidden Away

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If a boy disappears and nobody notices, is he really gone? Hisaki Fujishiro's withdrawal had been almost imperceptible, as hard to gauge as the ebb of a high tide. Even his mother failed to see the signposts, Fujishiro recalls: the elementary-school bullying that broke one of his fingers, the obsession with computer games, the increasing hours spent cloistered in his cluttered bedroom. These were, it seemed, the normal teethings of a preteen in postindustrial Tokyo, just another geeky kid wandering awkwardly through childhood. But gradually Fujishiro retreated completely.

The first tangible danger sign was an obsessive-compulsive disorder that manifested in Fujishiro when he entered junior high. He would write a character, erase it and rewrite it hundreds of times. Or he would frenetically wash his textbooks, as if the act of scrubbing them would somehow cleanse his troubled mind. Despite his eccentricities, Fujishiro managed to enter Tokyo's Chuo University in the mid-1990s. But soon he had withdrawn almost completely into the safety of his little room in student housing. Most days he would go to bed early and sleep through the morning, only venturing outside for exams or to buy a stash of junk food at the local 7-Eleven. He had no friends, preferring to spend his time with car magazines, which were stacked to the ceiling. "My curtains were always closed," recalls Fujishiro, now 29. "I didn't feel like I had a place where I belonged."

Fujishiro was hardly alone in his terrifying isolation. A generation of Japanese youngsters has dropped out of society entirely, unable to cope, it seems, with the rapid syncopation of life in Asia's most developed nation. The phenomenon has been dubbed hikikomori, or social withdrawal, by psychiatrist Tamaki Saito, who estimates that one in every 40 Japanese households has such a loner. That's an astounding 1 million social dropouts, most of whom are male. For Fujishiro, a support group at his university coaxed him out of his room, and he has now started reintegrating into society after eight years of seclusion. Today, he runs an online outreach program for other hikikomori slowly emerging from their shells. So far the disease has been diagnosed only in Japan, except for a handful of cases in South Korea. But these alienated youngsters might be a harbinger of what's to come for the rest of Asia, emblems of a continent hurtling so quickly into the future that its citizens have few tools to cope with the dizzying speeds.

Asia's mental health is, more than ever, in a perilous state. The Global Burden of Disease study commissioned jointly by the World Bank, the World Health Organization (WHO) and Harvard University predicts that by 2020 depression will be the leading cause of disability in Asia, measured by the number of years a person lives with a debilitating health condition. Already, mental illnesses account for five of the 10 leading causes of disability in Asia, including disorders such as depression and schizophrenia. That's a bigger health burden to the continent than cancer. A WHO study found that as many as one-quarter of all Indians currently suffer from some sort of mental illness. The region also boasts some of the highest suicide rates in the world. In China, for instance, suicide is the No. 1 cause of death among those aged 18-34, according to the Beijing Suicide Research and Prevention Center. At least 250,000 Chinese have killed themselves each year since the mid-1990s.

Yet only a small percentage of these troubled individuals ever seek help—or even possess the opportunity to do so. In Asia's most developed countries, ordered, Confucian cultures are loath to confront mental illness. Its victims commonly endure workplace discrimination, receive scant family support and feel obliged to hide their symptoms for fear of unsettling the people around them. Du Yasong, a psychiatrist at the Huashan Hospital in Shanghai, estimates that as many as one-third of all people who go to general practitioners in China are actually suffering from mental-health problems expressed psychosomatically through symptoms such as headaches or insomnia. Yet 95% of those with depression in China are untreated, according to Ji Jianlin, a medical professor at Shanghai's Fudan University who advises the central government on mental-health policy. Japan has the highest number of hospitalized, mentally ill patients in the world, yet psychiatry is still considered a crackpot discipline by many doctors there. "There is so much stigma when it comes to mental health," says Osamu Tajima, a leading psychiatrist in Tokyo. "The perception that it's a personality weakness prevails not just among 'normal' people. I've heard many doctors tell patients to stop complaining and tough it out."

Even when the severity of the problem is acknowledged, treatment is hampered by a disastrous lack of resources. This is especially true in Asia's poorer countries, where conditions for the mentally ill are often horrific. Many patients are locked up in hospitals no better than prisons. At the Panti Bina Laras Cipayung mental-health center in east Jakarta, just 10 minutes off a modern expressway, the air is thick with flies and the stench of feces. Originally intended for 200 patients, the government-run facility is crammed with 305 inmates. Most are naked, some are shackled or chained to window bars. Others, emaciated or showing oozing lesions, curl up on the soiled floor of the latrines. A doctor stops by the center only once a week for two to three hours; he has numerous other similar institutions to attend to. Though the center's number of patients has nearly doubled since 1996, its funding has not increased because of the weak economy—less than $1 is spent on each patient per day.

Indeed, most Asian nations spend tragically small amounts on mental-health care. In Cambodia, for instance, the country's entire mental-health budget is far less than what it would take to fund one topflight mental hospital in the U.S. In Pakistan, the government has all but given up on caring for the mentally ill and private donors have had to pick up the slack. More than 1,000 mentally ill patients live jammed together in the privately funded Karachi commune called Edhi Village, run by the prominent social worker Abdus Sattar Edhi. Iron gates lock the inmates in, some of whom, stark naked, slam their heads against the walls of their dark cells. "Our center is becoming a dumping ground for people who consider mentally ill people as the dirt of society," says Ghazanfar Karim, the complex's overburdened supervisor.

The grim irony of Asia's mental-health crisis is that it seems to be escalating even while much of the region is getting richer. Some experts see the continent's transformation as a profoundly mixed blessing, carrying with it dreams of cell phones and cable for all but also exacting an immense psychological toll on those who are struggling to keep up with the manic pace of change. Tradition and a sense of security have given way to upheaval and uncertainty. A farmer born of farmers, the father of future farmers, would work from dawn to dusk like everyone else he knew. Because he entertained no hope of an alternative lifestyle, he didn't agonize over one. But today the characteristics of a modern existence—the potential to get ahead, the rat race, even the crushing traffic—mean that Asians feel more psychological pressure than ever before. Psychiatrists in China, for instance, estimate that the rate of anxiety disorders is higher now than it was during the chaotic years of the Cultural Revolution. This, then, is the dark side of Asia's economic miracle.



 

Money Disorder
Born to peasants in china's south central province of Sichuan, Song L. had wanted to go to Shanghai for as long as he could remember. For him, China's biggest city was where dreams were made, where farmers morphed into millionaires. In truth, Shanghai is also where thousands of migrants lose their way in a pell-mell rush to riches. Fudan University professor Ji estimates that the incidence of mental illness among China's 100 million migrants might be twice as high as in the rest of Chinese society, due to the pressures of existing on the margins both economically and socially. But when Song headed to the big city in 2000 for construction work, he knew only of Shanghai's possibilities. At first, things went well for the then 19-year-old, but an altercation with a co-worker who accused him of shoddy workmanship cost him his job. "I couldn't eat, I couldn't sleep and I felt dizzy all the time," Song recalls. "When I closed my eyes and tried to sleep, I had nightmares where everything was spinning."

Song soon landed another job, but the dizziness didn't subside—a dangerous condition for a man who was supposed to make his living scrambling up the half-built skeletons of Shanghai's skyscrapers. He was quickly fired again. After 19 years in a tightly knit village, he was now alone in the city. "No one could help me," says Song. "All I had to keep me company were my thoughts, but my thoughts were already bad." Details of events after his second sacking are jumbled in Song's clouded mind: there was a desperate 16-hour, standing-room-only train ride up to Beijing, where he had heard of a job opening; a curt foreman who wouldn't take Song because he didn't look sturdy enough; and—the final blow—a robbery that stripped him of most of his savings. After that, Song wandered the streets for days—or was it months? He doesn't remember. Everywhere he went, the dizziness followed, even to the jail where Song was locked up for 30 days as a vagrant. "Sometimes I would see other people like me, alone, walking the streets, and I wondered if they had problems too, and wanted to make friends," he says. "But when I would go up to them, they would turn away."

One morning last spring, Song decided he wanted to die. He gathered his final pennies, bought some pesticide and swallowed it. When he woke up in a hospital, a nurse derided him for being cowardly and a drain on medical resources. "The nurse told me not to waste her time," says Song. "She said I was so stupid that I couldn't even kill myself correctly." Upon finding out that Song had no money, she forced him to check out of the hospital the next day, even though his throat still burned from the poison. No one came to pick him up, because no one knew he was there. Even today, Song does not know what to call the dizziness and bad thoughts that continue to haunt him. He has never heard of the word depression. All he knows is that he is a failure. "I cannot go home now," he says. "I would be an embarrassment to my parents and they would lose face in our village."

The vast majority of China's burgeoning mental-health patients suffer in silence. The nation's psychiatrists have seen a remarkable upswing in the kinds of mental disease linked to fast-paced societies, particularly depression and anxiety disorders. But, says Professor Ji, "Outside the big cities, most doctors have never heard of things like anxiety disorders or obsessive-compulsive disorders or even depression. So most people are never treated." According to the Global Burden of Disease survey, mental health constitutes only 2% of China's health budget, but psychiatric disorders account for 20% of the nation's health burden. The situation is particularly acute for serious mental diseases. The same study asserts that although 60% of schizophrenics are treated in hospitals in the U.S., 90% of China's schizophrenics remain hidden at home without access to medication or therapy. "Many people in China just want to hide the mentally ill person at home," says Du of Huashan Hospital. "They don't want outside people to see their crazy relative and think they are crazy too." Not that most could afford the cost of treating such major illnesses. Only about 15% of mainlanders currently have health insurance, and in most places expensive antipsychotic medicine is not subsidized.

The continuing stigma of mental disease in China—and, indeed, in much of Asia—is so pervasive that even the caregivers fall prey to misconceptions. Nurses who worked with Canadian psychiatrist Michael Phillips in the town of Shashi in central China confided to him that they didn't tell their families the true nature of their work, because it was widely believed that mental illness is contagious. Such ignorance isn't surprising given that many nursing schools in China don't even offer courses on psychiatry—it only became a formal discipline in mainland universities in 1995. There are only 2,000 fully qualified psychiatrists for a country of 1.3 billion people, compared with 10.5 psychiatrists per 100,000 in the U.S. The majority of China's psychiatrists never chose their field: they were assigned to it by their medical school.

Nevertheless, there are hopeful signs that China is trying to combat its growing mental-health scourge. The country recently passed a law that tries to address the basic rights of victims through education and increased funding for mental-health care. But as is often the case in China, the law has been implemented fully only in the big cities. In Shanghai, mental hospitals are clean, safe and orderly. But several Western-trained Chinese psychiatrists in the metropolis wonder whether overmedication is the cause of the eerily quiet halls. Indeed, the country still combats mental health by focusing on control—a fundamental difference with the West, where psychiatric disorders are recognized as a medical condition that often can be treated with therapy as well as drugs. By contrast, in East Asia social deviance is an issue typically addressed by the law. In China, it is the Ministry of Public Security that oversees many of the country's mental-health policies, not the Ministry of Health. Until recently the security bureau was also in charge of the nation's suicide statistics—and did not make them public. "We are still not facing up to our mental-health problem fully," says Du. "Unless all of us face up to the crisis, things will not change enough. We will be rich, but we will be sick."



 

War Wounds
Perhaps no country in asia needs mental-health care more than Cambodia, a tormented nation where the scars of the 1975-79 Khmer Rouge regime are still fresh even a quarter-century later. According to a survey conducted by the Transcultural Psychosocial Organization (TPO), an NGO with ties to the WHO, 75% of adult Cambodians who lived through the Khmer Rouge era suffer from either extreme stress or post-traumatic stress disorder. Children born to this broken generation haven't fared much better. Aid workers estimate that 40% of young Cambodians suffer from stress disorders caused by growing up in a tattered social network. Yet in all of Cambodia there is not a single inpatient mental hospital. The nation of 11 million has only 20 psychiatrists. Mental-health funding didn't even figure into the national budget until nine years ago. "The mental-health situation is bad in many countries," says Muny Sothara, a psychiatrist at an outpatient clinic at Preah Bat Norodom Sihanouk Hospital in the capital, Phnom Penh. "But I don't know of any place worse than Cambodia."

Every day, hundreds of bedraggled citizens line up from dawn at the Preah Bat hospital's mental-health clinic. Most have traveled for hours by oxen-drawn cart or packed bus to reach the venue. Chan Muoy, a gaunt, 41-year-old snack vendor, has not been able to sleep soundly for years. Images of past torture creep into her mind before slumber does. Now, though, things have got even worse. Cambodia has just gone through dangerously polarizing parliamentary elections, and many fear that violence might erupt once again. So nervous is Chan Muoy that she has lost her appetite and the tortured flashbacks are beginning to blur the line between reality and hallucination. While speaking to a psychiatric nurse, Chan Muoy's eyes bulge out and dart wildly as she recounts her trauma: how her father, brother and sister were killed by the Khmer Rouge, the latter for the crime of stealing a potato; how a troop of machete-wielding child soldiers came to get her one night when she was 18 and lashed her to a post in crucifixion pose before inexplicably releasing her hours later; how she wandered the streets for years after that, suffering rapes and beatings. "Everyone has gone through hard times here," says Chan Muoy, who was diagnosed with post-traumatic stress disorder by the nurse. "I'm not unusual. We all relive bad memories that make us shake and cry."

The lack of mental-health infrastructure gives Cambodians few options to treat their woes. Kum Kim, a 47-year-old from Kampong Thom province, was diagnosed as a schizophrenic by a health worker from TPO earlier this year. She says evil spirits poke sticks through the floor slats sometimes when she is resting in her wooden, stilted house. She says she must hop around her home to avoid the sharp jabs. Desperate for help, she goes to a krukmai, or witch doctor, named Son Mao. The krukmai's house—the only one in the village whose owners can afford a corrugated iron roof—has been prepared for Kum Kim's visit. There is an offering of fruit on the floor and whirls of incense meant to lure the village spirits in for a chat. As pigs squeal nearby, the krukmai touches Kum Kim's forehead and conjures up the spirits. They tell her that Kum Kim has been possessed by evil spirits. The reason? While Kum Kim's husband was commune chief many years ago, he promised to build a road for the village. Yet he never did. Now, the spirits are out to punish the whole family. "If the spirits are angry, you have to soothe them," explains Son Mao. "Once they forgive you, your craziness is gone."

Despite the krukmai's ministrations, Kum Kim's craziness has not disappeared. The spirits in her house still jab her with pointed sticks. Other families in the village have begun shunning her family, worried that the spirits might haunt them, too. In Cambodia, though, the haunted seem too numerous to avoid. "So many people are sick in the head here," says Chea Dany, a nurse at the Preah Bat hospital. "But no one wants to be with them. Our society is divided into two: people who are sick, and people who are O.K. and want to ignore the sick. We cannot grow up as a country if we are divided like this."



 

Suicide Nation
The placid postwar history of japan has little in common with the devastation Cambodia has endured. In Japan the streets are neat, and the government coffers are full despite more than a decade of economic stagnation. And yet there is a melancholy in the country that has caused more than 30,000 Japanese to commit suicide every year since 1998, compared with fewer than 15,000 a year in the 1970s. That's the highest suicide rate in East Asia, and one of the highest in the world. In part, the malaise that is gripping Japan seems to be a product of a hyper-commercial society where so many feel the need to compete—and so many fall apart when they slip behind. "We are very developed economically, but Japanese are still intent on getting ahead," says Yukio Saito, who runs a suicide-prevention hot line headquartered in Tokyo. "That pressure makes it very hard to sustain a healthy life."

To its credit, Japan has tried to heal its perennially depressed populace. Already, the nation has the most inpatient psychiatric beds in the world, and recent regulations have raised standards at private hospitals where care was often substandard. Government bureaucrats have also loosened stringent regulations on imports of Prozac and other badly needed medication. There has been a push to allocate more money for outpatient care and community-based education through posters. And on the Chuo train line, a well-known final destination for the terminally depressed, local authorities have installed mirrors in the train tunnel because studies show that looking at one's own reflection helps check suicidal impulses.

Yet, for all its efforts, Japan's suicide statistics remain desperately high. The phenomenon strikes most frequently among middle-aged men, precisely the same group most affected by Japan's long economic downturn and ensuing corporate restructuring. Among government bureaucrats, for instance, suicide is the second leading cause of death. "These people, who were used to lifetime employment, have seen a huge shift in the social system," says Saito. "But they can't admit to themselves that they're depressed, and they don't see any other noble way out." Even suicide itself is a shameful topic—ironic for a nation weaned on tales of kamikaze pilots and hara-kiri samurai. Saito remembers talking to a widow who couldn't admit to her family and friends that her husband had committed suicide. "She told everyone he died of a heart attack," he recalls. "That was the best way not to embarrass the family and his company."

In Japan, as in many other East Asian nations, such avoidance of social humiliation guides people's lives. "In America, people talk about going to the psychiatrist like going to the grocery store," says Tokyo-based psychiatrist Osamu Tajima. "But here, it's still quite taboo." Even after several nationwide education campaigns, mental illness is still widely seen in Japan as largely incurable. And though mental-health spending is higher in Japan than in other Asian nations, the country's legislation allows mental hospitals to have up to 48 patients per doctor, while regular hospitals are limited to just 16 patients per physician.

In tackling Asia's mental-health crisis, perhaps the most important task is to make smart spending a priority. Eight years ago, South Korean government officials tried just that, shifting resources from full-fledged mental institutions to community mental-health centers. The majority of patients who visit the 40 nationwide centers suffer from severe mental illnesses such as schizophrenia and bipolar disorder. But with rehabilitation courses and occupational training, many can reintegrate into a society that once shunned them. "Helping patients realize that they can manage their illness without being institutionalized is my duty," says Hong Joo Eun, who heads the Sungdong district community mental-health center in Seoul. Still, Hong notes that staff at such centers are paid half of what those in general hospitals earn, and the turnover rate among center workers is high.

The weight of battling on the front line of Asia's mental-health epidemic seems to hang heavy on psychiatrist Tajima. Sitting in his claustrophobic, fluorescent-lit consulting room in Tokyo, he rubs his eyes and cups his head in his hands. He has a bad headache that simply will not go away. Then, Tajima looks up and smiles a peculiarly Japanese smile—half apology, half wistfulness, without a hint of humor in it. "You know, I fit the profile of a high-risk suicide candidate in Japan," he says, massaging his temples. "I am a middle-aged man who is overworked and can't see that situation changing anytime soon." And with that thought, Tajima bows his head ever so politely and walks slowly out of the room.