Images of an Imagined Future: Photographing Deinstitutionalization in a Developing World

David Robertson // In the 1950s, the World Health Organization (WHO) engaged in a global effort to improve the treatment of institutionalized psychiatric patients. In the newly coined “developing nations” this support tended to target those in which a sizeable psychiatric infrastructure was already in place, including postcolonial nations like India and the Philippines. A leading goal of these efforts was to replicate in developing nations methods of non-custodial care, then being expanded in many developed countries under the rubric of deinstitutionalization. An internal WHO report from 1953 capturing this agenda suggested that ‘as a community’s economic development progresses the functions of the psychiatric hospital will extend beyond the care of [severely disturbed patients] as has already happened in all the countries of Western Europe and North America.’[1] Extending deinstitutionalization globally primarily meant transforming asylums into more open and community-engaged spaces and providing some of the treatments availed by modern psychiatry such as electroconvulsive therapy (ECT) and antipsychotic medications.

Today, a small collection of photos survives documenting some of these projects. Examining these photos, it is clear such interventions were conceived as bringing a psychiatric enlightenment to the developing world that was thought to parallel its ongoing socioeconomic development. In the photos and reports from the era, psychiatry was regularly positioned as an enabler of social progress and development. A report from 1962, for instance, noted that the rejuvenation of backward institutional conditions in developing countries ‘provides an opportunity to experiment and to profit from the experience and the mistakes of the more advanced countries.’[2] Contrasted with the global situation which actually arose, the photos encapsulate a developmental vision that never quite came to fruition.

Below are two early images documenting the institutional conditions of the era. The first is an asylum in India and the second is the Mandaluyong Mental Hospital in Manila, the Philippines. In both, patients are seen sitting and wandering around the walled hospital grounds. Mandaluyong, designed to accommodate one thousand patients, was around this time (c.1960) accommodating in excess of four times that number.

IMG_2204
Photo by Ajaib S. Kochar for World Health Organization. SEARO MENTAL HEALTH.
India, 1972. WHO/16259: Published in the WHO Photo Library, ref. WHO_A_010618.
Manila
Photo by Eric Schwab for World Health Organization. WPRO MENTAL HEALTH.
Philippines, 1960. WHO/6810: Published in the WHO Photo Library, ref. WHO_A_012798.

Despite the evidently overcrowded conditions, the photo of Mandaluyong was said to demonstrate the progressive transformation of the institution ‘into a place for treatment and cure’ where the earlier ‘iron bars and grills within the patio compound’ had been removed.

The photos often highlight such processes of rejuvenation. In the following photo from Mandaluyong, for instance, Filipino psychiatrist Manuel Escudero is pictured, bright smile on his face, while overlooking the conversion of the hospital grounds. The image depicts the metamorphosis of a place of closed restraint and isolation into a modern mental hospital. ‘Under the guidance of Dr. Manuel Escudero,’ reads text accompanying one photo, ‘an “insane asylum” is being transformed into a place for treatment and cure where anyone can go for advice and assistance.’ In addition to demonstrating the ongoing labor necessary to modernize Malaysian psychiatric institutions, it is easy to see such images as signifying the way deinstitutionalization was imagined to be part and parcel of socioeconomic development more generally.

Escudero Philippines
Photo by Eric Schwab for World Health Organization. WPRO MENTAL HEALTH. Philippines, 1960. WHO/6791: Published in the WHO Photo Library, ref. WHO_A_012779.

In a similar photo, ‘criminally insane patients’ at Mandaluyong are photographed under supervision by the hospital’s neurologist (dressed in white and wearing the large, wide-brimmed hat) while digging terraces for an open amphitheater.

Laborers Philippines
Photo by Eric Schwab for World Health Organization. WPRO MENTAL HEALTH. Philippines, 1960. WHO/6807: Published in the WHO Photo Library, ref. WHO_A_012795.

The images couple themes of rehabilitation and rejuvenation with the labor and technical supervision thought necessary for modernization. Such imagery is reinforced by later photos demonstrating the fruits of such labor. In the following picture, a recently built creative gardening section is shown.

Creative gardening by patients
Photo by Eric Schwab for World Health Organization. WPRO MENTAL HEALTH. Philippines, 1960. WHO/6803: Published in the WHO Photo Library, ref. WHO_A_012791.

Another shows Dr Manuel Escudero outlining the progress of his work at Mandaluyong to a team of visiting officials. Scrawled on the blackboard are such achievements as ‘restraints very much absent’ and ‘more tranquilizing drugs to be used.’

Escudero blackboard
Photo by Eric Schwab for World Health Organization. WPRO MENTAL HEALTH. Philippines, 1960. WHO/6793: Published in the WHO Photo Library, ref. WHO_A_012781.

In their efforts to document the developments taking place before them, photographers also depicted the introduction of modern treatments. The following photo from a mental hospital in Cali, Colombia, depicts patients and nursing staff engaged in informal dance as part of newly introduced practices of group therapy.

Dancing patients Colombia
Image obtained from: León, Carlos A. “Brighter Prospects.” World Health: The Magazine of the World Health Organization, October 1974, p. 30.

Another depicts hospital staff at Mandaluyong attending to a patient who has just completed a session of ECT.

ECT Philippines
Photo by Eric Schwab for World Health Organization. WPRO MENTAL HEALTH. Philippines, 1960. WHO/6829: Published in the WHO Photo Library, ref.  WHO_A_012797.

Progress was sometimes reiterated by documenting the conditions preceding such changes. In an article entitled ‘Brighter Prospects,’ the Colombian psychiatrist Carlos León displayed the following patient, noting that despite his apparent cheerfulness ‘his recovery and rehabilitation were all too likely to be retarded by such primitive conditions.’

Imprisoned in Colombia
Image obtained from: León, Carlos A. “Brighter Prospects.” World Health: The Magazine of the World Health Organization, October 1974, p. 29.

Alongside another image of a withdrawn patient, León wrote favorably of the potential new pharmacological treatments of the era: ‘Today, a distracted and bewildered individual; tomorrow, perhaps, another useful citizen.’[3] Contrasting images of unoccupied and restrained patients in dull, concrete institutions with images of white-jacketed doctors and engaged patients emphasized that development and the provision of the scientific tools of psychiatry were part and parcel of the modernization process.

While such a contrast creates an attractive teleological narrative, historical developments have not been so simple. Globally, deinstitutionalization has been neither a uniform nor a linear process. In developed countries it has had a range of consequences including escalating prison numbers (most dramatically in the United States) and a collapse in the number of hospital beds provided for psychiatric patients.[4] Meanwhile, the number of psychiatrists available in lower-income countries remains grossly inadequate, and mental health is often low on the ladder of public health priorities. Increasingly, new stop-gap measures such as the training of lay counselors is resorted to “where there is no psychiatrist,” to quote the title of one contribution to this emerging form of intervention.[5]

Far from following the script of socioeconomic development accompanied by psychiatric enlightenment that is suggested by these photos, the trajectory of mental health institutions globally has been overwhelmingly uneven. In some lower-income countries, confinement and restraint continue as practices sometimes used for dealing with severely psychotic patients. This is also the case in some wealthier nations, Indonesia being one prominent example.[6] Like narratives of “epidemiological transition” in global health more broadly, the international expansion of psychiatry’s institutions, practices, and personnel over the past seventy years has taken diverse routes with often unpredictable outcomes.[7] None of this, of course, is to cast aspersion on all the work undertaken by the WHO and collaborating institutions and physicians. But revisiting photos from this era provides a vivid reminder of the failure to bring into being a world that was not too long ago believed to be in utero.

– Photos reproduced with permission from the World Health Organization. Some photos have been edited to ensure anonymity.

References

[1] “Third Report: The Community Mental Hospital,” (Geneva: World Health Organization, 1953), p. 3.

[2] “WHO and Mental Health, 1949-1961,”  (Geneva: World Health Organization, 1962), p. 7.

[3] Carlos A. León, “Brighter Prospects,” World Health: The Magazine of the World Health Organization, October 1974, p. 33.

[4] Dae-Young Kim, “Psychiatric Deinstitutionalization and Prison Population Growth: A Critical Literature Review and Its Implications,” Criminal Justice Policy Review 27, no. 1 (2016).

[5] Vikram Patel, Where There Is No Psychiatrist: A Mental Health Care Manual (Glasgow: Gaskell, 2002).

[6] Hans Pols and Sasanto Wibisono, “Psychiatry and Mental Health Care in Indonesia from Colonial to Modern Times,” in Mental Health in Asia and the Pacific: Historical and Cultural Perspectives, ed. Harry Minas and Milton Lewis (New York: Springer, 2017).

[7] Julie Livingstone, Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic (Durham: Duke University Press, 2012), p. 34.

 

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