37. Tindog Tacloban! – The School Program

MSF missions take a massive amount of coordination and effort, spanning several continents in real-time, which in turn can be intense, complicated and trying. I’ve made mention before of the logistical concerns of putting up to 60 staff on the ground in Tacloban soon after the super-typhoon. Attending to personal needs of the humanitarian staff continues apace while sourcing out a place to set up a hospital, hiring staff, and getting everything from surgical amphitheatres, neonatal units, mobile/outreach clinics, and mental health services up and running.

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Then the first patient steps through the tent flap of the outpatient department and is told that they will be assessed and treated without cost for these services and medications provided.

At times, the bodily needs are easier to understand than mental health needs. We see a broken bone, hear the cough, and can measure the blood-glucose level. The reasons that one comes to mental health care attention are often due to conspicuous absences of functioning at home, socially, or at work or school. In children, especially. A quiet child, decrease in concentration or attention, fearfulness at night and some avoidance of social play… these things could go unrecognized.

The elementary school program was set up prior to my arrival. It is finishing this week, as the Tacloban Project is in its termination phase, and the school children go on break at the end of March. This was an ambitious project, and by that I mean it was a well-thought-out, resource-intensive, and focused intervention. That MSF has in place the will, technical expertise and resources to undertake this mission is one of the reasons that I have come back for a third mission with them.

A psychiatrist was included in one of the early waves of staff on the ground, and she did a quick but thorough assessment of the community needs while getting the program started. Soon after a child psychiatrist and psychologist were hired, and they did the legwork of working with the local health and education authorities toward identifying schools and children in need of psychological services.

Enter Sherman, the irritable Raccoon. Not a typo.

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The children, about ten per session, huddle in a circle while one of our staff reads from this storybook, “A Terrible Thing Happened” by Mararet Holmes.

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The students come from two coastal elementary schools which were identified as the hardest hit by the typhoon. The numbers are staggering. 67 children died in the one school, which represented about 15% of the total 425 students. 37 students died of 287 in the other school. Words fail when trying to capture the tragedy, and the heartbreak.

Beside the school, in front of the neighbourhood church, is a makeshift cemetery. The kids, their families, and teachers walk by it every day.

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And this is where Sherman comes in. Something bad happened to the young Raccoon, and he begins to show signs of fear, stress, and acting-out behaviour. There are four sessions with each group, the first three involve reading the first, second and final third of the storybook.

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After the first session, the children are asked to draw on paper what Sherman may be afraid of. After the second, where it is shown that Sherman is having some difficulty in school and with friends/family, and tries ways to calm himself, the children are asked how Sherman is coping with the “very bad thing,” and how he is finding ways to self-soothe or pacify his inner turmoil. The final third of the book involves a therapist that Sherman talks to, and eventually he feels better. The children are asked to draw their thoughts about Sherman now that he feels better, and what Sherman might do with his re-found happiness.

The children explain to one of our four program staff the meaning of their drawings, and the themes are tracked throughout the four weeks. It is a therapeutic process on its own, but when some students are clearly exhibiting a decline in school functioning (sometimes to the point of refusing to attend school), more intensive work is done. Caregivers and teachers are consulted and the child is rated on an MSF-generated cross-culturally validated tool called the PSYCa, to identify what symptoms are evident and should be targeted. Individual therapy is done with the child and caregivers.

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“Sherman saw three ghosts and he was scared of ghosts. He stays in the house to stay away from ghosts.”

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“Sherman saw a dead person beside a tree where it was buried. He is scared of dead people. Sometimes he prays for the dead who are already in heaven. Sherman stays inside his home brushing his teeth”

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“There are dead people buried outside the house of Sherman, but he is not scared of them. He just plays inside the house with his dog.”

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“The three figures in the mountain are zombies looking for victims but they won’t find any because there is no one in the mountain. The little house is Sherman’s where he saw the monster Caswarg. But he prayed and went to his mother and father after he saw the Caswarg, and that’s why he is not afraid anymore.”

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As the weeks have passed, and the students in need of individual attention decrease, our program is coming to a close.

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The wind and rain comes and the children still exhibit some hesitancy or fear, but it passes quickly for most, and a song is sung. Most students now run outside to play in the rain. The Principal, the teachers, the parents, they thank us for our work with their students, their children, their community. I tell them that this is why MSF is on the ground, and that it was a privilege to have been allowed into the schools and to do the therapeutic sessions with them. I tell them that this is why, in part, MSF is in the country. It is a feel-good moment.

Our project staff deserve the pride that they have taken in their work. Over 100 children per week took part in the storybook sessions, and five to ten per week had individual therapy.

Primary health care includes mental health care. If we don’t have staff who are knowledgeable and committed to mental health work, either in a disaster setting or in a longer-term crisis setting, we are missing suffering that is identifiable and treatable. That this is crucial work is as clear as day. To those who decided to get a mental health program off the ground quickly, think of the children who, when they come across ghosts or the monster Caswarg along their fantastical journeys, are no longer afraid and play outdoors.

 

36. Tindog Tacloban! – An 11 Year-Old Boy

The names and some details of the case have been changed to ensure anonymity. Melan provided permission to write about his story, with the understanding that it would be potentially read on the internet by people all over the world, and would describe some of his experiences of the previous several years. His mother provided written permission.

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At around 11am on Saturday, I was asked to see an 11 year-old boy, Melan, who had been brought to the MSF Outpatient Department for a fever and sneezing.  The physician who saw him was advised that since the typhoon, Melan has been more isolated and played less with friends, and thus made the referral to mental health services.

Melan looked like any boy his age.  He had a mop of shaggy hair, jeans, and avoided eye contact most of the time.  He peered up now and again, and had a sad look that wouldn’t shake.  I told him that he didn’t have to be here, that he could leave and come back another day, but it might be good for him to talk given the sadness his mother described.  He thought it best to continue, despite his hesitancy.  He wouldn’t speak for a little while, but eventually said that he has been “feeling down because of the storm.”  Regarding his experience of the typhoon, he said that “the winds tore the roof open and trees fell down… tidal wave… many things happened.”

Melan’s mother watched with an uncomfortable anguish as he spoke through his tears, remaining silent yet present as he expressed himself. 

He was in the family home, with his mother and cousin (age 6).  He awoke around 5am when the roof-top ripped off his house.  He had heard that a big storm was coming, but he thought it would be like the many other storms that he had witnessed, so he was not worried when he went to sleep.  The first floor of the house flooded, and Melan joined his mother and cousin for the next four hours.  He spoke with his mother throughout the storm, and he felt that she and he “were fine.”  When the winds died down, he walked outside, and found that “many things were destroyed… electrical posts, houses, almost everything in the house, roads.”  He thought that his house could have collapsed, as many others had.  Melan did not see any dead bodies, but heard of casualties, and of others seeing bodies in the street. 

Melan had no close friends or family who died in the storm, nor was anyone in his school injured or killed. 

After the Typhoon, like so many others, Melan and his mother went to Manila to stay with family.  He felt safe in Manila, and thought of the storm “sometimes.”  He returned to Tacloban five days prior to having presented to the MSF hospital.  He was sleeping relatively well, and had no nightmares, but thought of the storm during the daytime “sometimes.”  He could go many hours without any thoughts of the storm.  As he said this, however, tears washed down his cheeks.  I asked where the tears were from, and he answered, “the people who were killed in the destruction.”  He could not identify who, just that they were people from his city. 

At this point his mother was crying quietly, and I was quite taken with his story.  It was becoming less clear, however, what was driving his sadness and self-isolating behaviour three months after the incident.  Melan had no psych history, was on no medications and had an unremarkable medical history.  Nobody in his family had ever been seen by psychological services of any kind. 

I asked Melan if the darkening clouds, rain and winds were worrying to him, and he said that they were not.  When asked what he would say to a younger child if they were frightened in a storm, he responded: “calm down, there is nothing to be afraid of.”  And he reiterated that this was his belief, not simply the consolation of an innocent.  Melan did not recall having been frightened by a storm or any other act of nature prior to or since typhoon Yolanda. 

The most difficult part of the memory of the typhoon was “the part where many people died… the part that friends or family could die… I could be alone.” 

This could be called existential angst.  Death and loneliness drive many symptoms, but as the discussion continued, it did not seem to be the generator of his almost palpable terror.  And then it came out.  When asked if there was any time in his life when Melan felt alone, powerless to what could happen next, he started to cry more forcefully, sometimes gulping air as he spoke. It was wrenching to me, and his mother put an arm around him as he continued. He spoke of the time when he was 7, and a 10 year-old male student “punched him” once and taunted him several times.  This bullying behaviour took place at and around school-time, and lasted about 1-2 months. 

Melan refused to go to school a few times, but his parents and teachers were, to his recollection, unaware of the problem.  The bully did not target Melan specifically, as he was known to bully the younger kids. On direct questioning, Melan said that the bully probably did not even know his name, and the bullying stopped because the older boy forgot about Melan. 

We spoke about feelings of helplessness and fear given circumstances out of our control.  Melan cried a fair bit, but decided to continue. 

We spoke of his father who had been a migrant worker in Dubai for 8 years, and how he has a good relationship with him, speaking on the phone every week, and seeing him once a year for a week. 

Melan’s plan for the near future was to “be with friends this week… try to forget about the past… not think of bullying.”  We set up an appointment for the following week. 

This story hints at many things.  I want to underscore something that has become glaringly apparent as time goes on in my career and life: that a sizeable chunk of human misery is perpetuated by factors within someone’s control, often discretionary.     

35. Tindog Tacloban! – The Outpatient Program

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The jeepney sets out at about 8:15am. It looks like a battered old short-bus, but instead of back seats, it has two long bench seats along the sides, and an open back and sides. If there is no air conditioning, this is the most comfortable way to … [Continue reading]

34. Tindog Tacloban! – The Boats

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I went this morning to see “the boats.” I had been asked several times if I’d seen them, so I got the sense that it was something to behold. I saw a few photos on the web, but it was hard to place the ships among the heaps of detritus from the … [Continue reading]

33. Tindog Tacloban! – Intro

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This blog is mirrored from the MSF site. Pictures are added. Date of initial publication: February 18, 2014.     This blog is mainly to get word out to friends and family regarding this mission.  There are a lot of questions coming my way, the … [Continue reading]

32. Tindog Tacloban! (link to MSF blog)

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http://blogs.msf.org/philippines/author/dr-steven-cohen/   These are the counsellors. Jil, Meliza, Russel, Jen, Jess, Melot, JG, Phrex.   … [Continue reading]

31. Correctional Psychiatry in Canada – Commentaries

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Commentary #1: Bridging the Gaps for Former Inmates with Serious Mental Illness Anthony C. Tamburello, MD, and Zoe¨ Selhi, MA, MD Serious mental illness is a prominent and vexing problem within the correctional systems of North America. Simpson … [Continue reading]

30. Correctional Psychiatry in Canada – Article

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  CHALLENGES FOR CANADA IN MEETING THE NEEDS OF PERSONS WITH SERIOUS MENTAL ILLNESS IN PRISON (Alexander I. F. Simpson, MB, ChB, BMedSci, Jeffry J. McMaster, MD, and Steven N. Cohen, MA, MD) The number of prison inmates is predicted to … [Continue reading]

29. Reflections on Chad and Sudan – The Rule of Law

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I get parking tickets now and again.  It happens.  Here’s how the conversation went semi-recently: I got a ticket Oh, that sucks.  Kind of. You’re just saying that, of course you’re pissed. Nope, not pissed at all.  In fact, I get a … [Continue reading]

28. Darfur, Sudan – The Magic Quarter

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Fast-forward to 2013.  I’ve been working as a forensic psychiatrist at CAMH in Toronto for about 4 years, and it’s been a fascinating apprenticeship and practice at the intersection of psychiatry and the law.  A multidisciplinary team assesses, … [Continue reading]