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The rise of the modern psychiatric movement in Malaysia derives its origins from its colonial heritage. Britain, as well as the Dutch in what is now Indonesian Borneo (Kalimantan), were busily exporting European concepts of illness and contemporary methods of care to their colonies. It should be noted from the outset that, as discussed in Chapter One, the developments in colonial Malaya were not greatly influential in East Malaysia. The position of Sarawak under the Brooke rule, for instance, can be seen to be an historical anomaly that was not specifically connected to British imperialism in Malaya, but that at the time the settlement of Singapore was counted as part of Crown territories in the Malayan region. The accession of Sarawak to the new Federation of Malaysia in 1963 tied its future firmly to that of the Peninsula, and eventually Singapore claimed independence from the Federation of Malaysia. All this lay in the future however, and prior to this period Sarawak evolved at a quite different pace, and under a very different system, in which the development of psychiatry appears to have played a very minor role in comparison to colonial Malaya.

European health care in Malaya was first introduced into urban areas and only progressed to remote rural locations with the expansion of colonial authority (Manderson, 1996). This is in keeping with general colonial policy that health care should primarily serve the expatriate population, whether civilian or military; and in this respect care of insanity was treated in the same spirit, with the siting of asylums in areas of British influence (Bhugra, 2001; McCulloch, 2001). Consequently, the first recorded lunatic asylum in Malaya was built near the regimental hospital under the auspices of the colonial authorities in Penang, a Crown possession for some decades since 1786, to cater, it is claimed, for primarily syphilitic European sailors (Baba, 1992; Deva, 1992). By 1829 however, there were a mere 25 inmates in the Penang asylum, 23 men and two women, almost all being Chinese and Indian (Tan and Wagner, 1971).

Commensurate with the rapid expansion of the asylum system earlier in nineteenth-century England, the rapidly growing colonial settlement of Singapore saw the sequential building of several asylums, commencing with a comparatively small ‘Insane Hospital’ in 1841, where previously the insane were abandoned to the indifferent care of the local gaol (Ng and Chee, 2006, Tan and Wagner, 1971; Shorter, 1997). Eventually this situation culminated in the establishment of the large ‘New Mental Hospital’ in 1928 (Ng and Chee, 2006). However, in the nineteenth and early twentieth century, despite colonial concerns that asylums were required in Singapore, this does not imply that the perceived prevalence of insanity was comparable with that of England in 1900, where it was almost 30% higher than in the Singaporean community (Teoh, 1971).

By 1887, however, an English psychiatrist by the name of William Gilmore Ellis was appointed to take charge of a newly built asylum in the recently established colonial settlement of Singapore (Ng and Chee, 2006). This building, constructed in 1885 on the Sepoy Lines, replaced the original asylum of 1862, which, it seems, had been built to cater for predominantly Asian migrant labour following a murder at the local gaol. Due to overcrowding of the asylum, however, apparently a policy of repatriation of chronically ill Chinese and Indian inmates commenced, duly resonating with the accounts of Ernst and Jackson in this regard.

A further institution was opened in Penang in 1860 but this did not remain for long, with the Sepoy Lines asylum at Singapore being subsequently obliged to absorb their internee population following closure (Murphy, 1971). The next institution on Peninsular Malaya was not established until circa 1910 when the Central Mental Hospital was built in Tanjong Rambutan, a few miles from the tin-mining town of Ipoh in Perak (Tan and Wagner, 1971). Its name was changed to Hospital Bahagia in 1971.

Returning to Gilmore Ellis’ Singapore asylum, admissions in the late nineteenth century were noted to come from as far afield as Bangkok and Australia, where, in the latter case at least, psychiatric services were considered to be far more rudimentary (Teoh, 1971). Although in South Australia, at least, there had been an attempt to model them on British counterparts as a need for asylum care was recognised due to the repercussions of migration on the mental health of colonial settlers (Piddock, 2004). Apart from the Straits Settlements (Penang and Singapore), cases were referred from the States of Johore, Malacca and Selangor; the quality of early psychiatric services in Malaya at this time was evidently by no means deficient in comparison with other nations (Teoh, 1971). Even at the original Singapore asylum the number of psychiatric beds per capita was roughly equivalent to that of Britain and ahead of America, with conditions for patients considerably preferable compared to the community and institutional abuses of the insane in North America (Geller and Harris, 1994; Murphy, 1971). A fact perhaps not so surprising when put in the context of asylums in the British Raj, which were often superior to those in Britain and supported by comparatively enlightened policies and rapid responses to reform (Keller, 2001; Ernst 2010). This, notwithstanding a revisionist critique of the colonial authorities neglect of the vagrant mentally ill Indian beyond the walls of the asylum, and the overcrowding and racially-based differences in treatment within them (Ernst, 2010)

To return to historical Singapore, the types of admission to the new asylum were varied, with the first case of neurosyphilis in the Asian local population noted in 1906. By comparison in England, Shorter (1997) argues that neurosyphilis rose to epidemic proportions swelling the numbers of nineteenth-century asylums and resulting in mania, paralysis, dementia and death, with further cases of morbidity due to a rise in alcohol abuse. Accordingly, from the beginnings of the twentieth century the socio-economics of the period dictated that 20% of all admissions to the Sepoy Lines asylum were suffering from signs of neurosyphilis. Whilst equally by 1906 in grim comparison it was noted that similarly alcoholic psychosis was beginning to replace illnesses caused by opium consumption (Teoh, 1971).

Prior to Gilmore Ellis’ supervision of the new Singapore asylum the original hospital in Stamford Raffles’ Singapore had an enviable discharge rate of 89% with most cases admitted suffering from acute psychotic attacks after the use of opium and other narcotics; this situation was not to last however (Murphy, 1971). Madness and ethnicity were already viewed by medical authorities of the time as following certain racially determined lines, and consequently Chinese migrant workers were perceived as suffering from their own distinct forms of insanity and increasingly so, as Victor Purcell states:

Insanity among the Chinese was attributed to drinking, opium-smoking and gambling, and in some measure to speculation … Chinese lunatics suffered from dementia mostly, whereas the other races had mania, the former being due to gambling and opium-smoking (Purcell, 1948: 65).

Gambling, use of opium and more notoriously venereal diseases were a feature of life for nineteenth-century colonial Malaya where migrant labour was overwhelmingly made up of male Asian workers from China and the Indian subcontinent. These men were largely brought to work in tin mines, on estates and railways, and in small private enterprises, although in Sarawak Chinese farming skills were sought (Chew, 1990). By contrast, immigrant women were largely brought to work in brothels serving Asian migrant and white expatriate masculine needs (Manderson, 1996). Prostitution however, carried its own penalties in the form of syphilis, which was initially a rare occurrence amongst non-Europeans.

General Paralysis of the Insane, a syphilitic infection of the brain which causes insanity, was never seen among Asiatics. Practically all cases were among those of European stock and it was then considered that the disease was peculiar to Europeans only and was a disease of civilised life running at high pressure (Teoh, 1971: 20).

The inference here being that the pressures that the white expatriate community suffered from were similar to those of the Asian expatriate community, whereby socially sanctioned conjugal relationships were unlikely in a social environment characterised by a lack of eligible females. British civil servants in Malaya, in common with other colonial regions, required permission to marry from their employers and this only after many years of service, which consequently gave rise to the institution of concubinage of local women (Stoler, 1991). This, Stoler argues, was an expedient policy that preserved the health of expatriate males and helped to secure their continued employment and contentment in foreign regions.

In relation to this point, Teoh notes that the majority of admissions to the Singapore asylum at this time were in an appalling state of health; with women admissions, few though they may have been, in the worst physical condition of all (1971). A plausible inference may be drawn under the circumstances that these were due to the ravages of a life of prostitution and its concomitant hazards, as much as from any other form of disease and hardship.

The low admission rates in Singapore at the turn of the nineteenth century have been in part attributed to the low percentage of women admissions, and this in turn due to very few numbers of women per capita in the community at this time, where the first case of puerperal insanity was admitted to the asylum as late as 1888 (Teoh, 1971; Ng and Chee, 2006). This has been estimated as standing in the region of three women to every 10 men, and as such represents a comparable situation to that of other conurbations of British influence in colonial Malaya during this general period (Tan and Wagner, 1971; Teoh, 1971). Nonetheless, this was not an isolated national anomaly, for in colonial Nigeria, there were three times as many male patients in psychiatric care as females, and where originally in the Ingutsheni Lunatic Asylum, no provision had been made for women at all (Sadowsky, 1999, Jackson, 2005).

These therefore, as Keller (2001) observes, create some significantly interesting anomalies when correlated with feminist studies of admission rates of women in England during the era, whereby according to Kromm (1994: 507), it denoted ‘a clear shift in the understanding of madness as a gendered disorder’. She goes on to argue that theatrical and pictorial representations increasingly depicted woman as the embodiment of madness in various postures of melancholia as opposed to mania (Kromm, 1994). Furthermore, Showalter (1985) argues that the over-representation of madness amongst women was far from being merely a nineteenth-century and twentieth-century phenomenon, but existed from the seventeenth century onwards.

To rehearse the analysis of these feminist studies of the feminisation of madness Denise Russell (1995: 18), in support of Kromm’s assertion that there existed a preponderance of women in British public mental hospitals in the nineteenth century, considers the late eighteenth-century interest in ‘specifically female problems’ as an origin of perceiving insanity as a gendered condition. It is argued that these forms of feminine pathology were dominated by the medical preoccupation with female sexuality and moral purity. In turn, this continues as a dominant discourse in relation to the labelling of women as suffering from mental illness (Barnes and Bowl, 2001; Ussher, 1991).

Joan Busfield (1994), however, contests the assertion of overwhelming numbers of nineteenth-century women in asylum care, and instead asserts that at least in relation to that century the empirical evidence pointing to proportional differences between male and female admission data is quite small. Statistical evidence notwithstanding, diagnosed insanity and high admission rates in the asylum system related to gender depended heavily on the institutionalised perception of woman as essentially associated with the likelihood of insanity.

Yet the Victorian era marked an important change in the discursive regimes that confined and controlled women, because it was in this period that the close association between femininity and pathology became firmly established with the scientific, literary and popular discourse: madness became synonymous with womanhood (Ussher, 1991: 64).

While the debate concerning the precise numbers of women in asylum care in previous centuries will no doubt continue, there has been little dissent concerning the claim that there has been a universal predominance of women diagnosed with mental illness in the twentieth century (Miles, 1988; Ramon, 1996; Ussher, 1991). Phyllis Chesler (1996: 46) baldly states that more women are being hospitalised with a diagnosis of mental illness than ‘at any other time in history’. These diagnoses are, she argues, predominantly affective depressive disorders in keeping with women’s subdued and passive presence in society, a topic also explored by Redfield Jamison (1996) in her personal account of bipolar depression. Chesler goes on to allude to the continuing dichotomised perceptions that have persisted, lying between the socially accepted, rewarded but inadequate role of the passive, melancholic female and her antithesis: that of the deplored voluble, ‘aggressive’, masculinised female counterpart.

When female depression swells to clinical proportions, it unfortunately doesn’t function as a role-release or respite. For example … ‘depressed’ women are even less verbally ‘hostile’ and ‘aggressive’ than non-depressed women; their ‘depression’ may serve as a way of keeping a deadly faith with their ‘feminine’ role (Chesler, 1996: 51).

Wetzel (2000) stands in agreement with Jennie Williams (1999) in arguing that in both the developed and developing world, conditions of oppression affect women living in patriarchal societies, such as Malaysia. These forms of oppression towards women include low status, poverty and exploitation, sexual violence and other acts of human rights violation (Barnes and Bowl, 2001; Wetzel, 2000). Other critiques have noted the relationship between mental distress and the oppression that marriage may impose on women, together with the escalated risk factor connected with the role of motherhood (Ramon, 1996; Ussher, 1991). This has accordingly resulted in a global bias towards a high risk of diagnosis of mental illness for women and their subsequent admission to institutional care.

Long term psychiatric intervention (based upon psychosexual theories) has been inappropriately applied to women throughout the world, when their real problems were poverty, violence and economics (Wetzel, 2000: 209).

Apart from the issue of gender bias, a further issue of interest for this study lies in the ethnic breakdown of admission rates during this period and subsequent decades. For example, in 1900 the Singapore asylums largely held Chinese and Indian migrants who formed the vast majority of inmates (Teoh, 1971). It is claimed that this situation continued over the next century and was comparable with other asylums in Malaya, such as in Penang (Tan and Wagner, 1971). The implications of continuing bias in this regard is considered in this study, in reference to patient admission at Hospital Tranquillity.

In relation to the issue of ethnic preponderance in contemporary psychiatric care in the West, a relatively small but important body of critique considers the issue of mental illness and the impact of migration and that of cultural dislocation, together with the effects of consequential separation of individuals from their supportive networks. Such analyses focus on the significance of ethnic bias of psychiatry in Britain where British-born men from African-Caribbean background have been predominancely diagnosed with schizophrenia (Nazroo, 1997; Rack, 1982). Furthermore, an interesting aspect of the escalated ethnic presence in psychiatric services noted in Britain, and which appears to hold significant import for modern Malaysia, is that subsequent generations are also at greater risk of diagnosis and hospitalisation, despite a level of familiarisation and acculturation in the adopted alien culture (Barnes and Bowl, 2001). This said, Ramon (1996) highlights the issue of class as being a further factor to consider along with ethnicity and migration. She argues that elements such as education and, presumably, upward social mobility can act as protective factors countering the effects of migration and cultural dislocation (Ramon, 1996). Suman Fernando (1995, 1999), however, draws a general conclusion of institutionalised racism encountering cultural difference; while others have considered the phenomenon in terms of actual illness and social stressors. In this vein Ajita Chakraborty (1991: 1208) condemns the ‘value-based and often racist undercurrents in psychiatry’ and goes on to note the fundamental tolerance of mental illness amongst families in India, with the inference that stigma is a persistent effect of Western colonial values. This in turn tends to corroborate the psychiatric assumption that most South-Asian psychiatric patients in Britain have a supportive family network and enjoy what Nazroo describes as a ‘protective culture’, having fewer mental-health needs than other immigrants (Nazroo, 1997: 7). Thus resonating with Teoh’s assumption that separation from ‘stable and emotional family support’ represented a significant risk factor for Indian male migrants in colonial Malaya (Teoh, 1971: 28).

Finally, in contemporary Britain Chinese psychiatric service users have equally been subject to stereotyping, in terms of the assumption that they enjoy a supportive and insular family network, leading to the relative abandonment of carers by the support services (Yee and Shun Au, 1997). In view of the Chinese diaspora and the issue of Chinese asylum admissions in colonial Malaya and Borneo, these latter-day assumptions may contain useful references in understanding the position of Chinese patients in the modern Malaysian psychiatric institution, as represented by Hospital Tranquillity (Kleinman, 1988b).

Back in nineteenth-century Singapore, Gilmore Ellis brought with him contemporary notions of therapeutic care that involved rehabilitative exercises, such as occupational labour; in keeping with British values of the day. These in all likelihood were gender normative activities, and for women revolved around the skills of the good housewife, and which are enacted on hospital wards to this day, as will be discussed further in Chapter Five (Gittins, 1998; Witz, 1992). Gilmore Ellis apparently diverted a considerable amount of Victorian energy and new enthusiasm to improving conditions for the mentally ill commensurate with up-to-date British practices:

In the first year he abolished strait jackets, got 87% of the patients occupied in one way or another, usually at rope-making or weaving in the workshops, instituted a new and better system of record keeping, prosecuted an attendant for ill treating a patient, and arranged for a Chinese Wayang to come and give entertainment (Murphy, 1971: 16).

In Penang, it would seem that such rehabilitative therapies had equally been introduced to patients there. A fascinating insight from a nineteenth century British superintendent who had served at asylums in both Penang and Calcutta stated that the ethnically diverse patients in Penang were far more amenable to ‘voluntary manual work’ than were the Bengalese patients or their Eurasian counterparts, in his experience (Ernst, 2010: 63).

In nineteenth century Singapore even the rudimentary after-care of discharged patients was not neglected; however, despite all these therapeutic improvements, Gilmore Ellis could not prevent a very high death rate from cholera and beri-beri amongst inmates. Acute cases with a rapid discharge rate were not typical admissions, as had been seen in the earlier Singapore institution. Now psychiatric chronicity and physical morbidity were the main characteristics of patients at the new asylum, a situation that would be replicated in the later running of psychiatric hospitals of colonial Kenya in the 1920s (McCulloch, 2001; Murphy, 1971). The high mortality rate caused by cholera and beri-beri epidemics ravaged the internee population. They were brought under control only to be subsequently replaced by syphilis and tuberculosis, so that the death rate was never below 20% and on occasions rose to 50% of admissions. Gilmore Ellis’s response was not complacent, where his own scientific investigations failed, saltwater baths and the curative effects of visits to the seaside succeeded in reducing the mortality rates quite considerably (Murphy, 1971).

In subsequent eras, these fairly benevolent regimes would be overtaken by new forms of treatment such as insulin coma therapy and lobotomy that, as Tai-Kwang Woon dryly notes, ‘did not bring any transient hope to the patients or stirred the enthusiasm of the staff’ (1971: 31). He goes on to note that medication was used to subdue and control patients, and where this failed, restraints in the form of strait jackets were applied. In the case of Hospital Tranquillity treatment included liberal uses of electro-convulsive therapy (ECT), supplemented by sessions of psychotherapy, under the therapeutic regime of the resident colonial alienist of the period.

Gilmore Ellis’s contribution to psychiatric care in Malaya can be seen to have been very much based in the tradition of moral treatment, whereby humane treatment and structured activities were seen to be a highly necessary component in achieving a ‘cure’. Unfortunately these early improvements were not sustained and deterioration in care in association with larger admissions began to take place (Teoh, 1971). In the West the loss of the earlier optimism towards effecting a cure for mental illness caused demoralisation amongst pioneering psychiatric professionals by the end of the nineteenth century (Shorter, 1997). This loss of vision could also be seen to be taking its toll on the standards of care even in the new Singapore asylum during this period. By 1909 Ellis had left to take up a new post as Chief Medical Officer in the settlement and a new chapter was opened in psychiatric care in colonial Malaya (Teoh, 1971).