34. Tindog Tacloban! – The Boats


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 storm.

The boats are massive. Bigger than the MSF staff housing structure that comfortably sleeps well over 20. Bigger than a standard sized apartment complex. The water surge brought them inland and then left them there after it retreated, simple as that. To ensure that they don’t topple over, stabilizing wedges have been put in. You have to crawl under one section of one boat’s hull to continue down one of the roads. It’s a bit freaky.

A fellow named Manolo came to chat with me. The Filipinos are near uniformly friendly. He asked me where I was from and who I worked with. Oddly enough, when I told him that I worked for MSF and we had a full hospital providing free medical care, notably dispensing no-cost medications, he was unaware of this. We joked about basketball with his friends, and then I set off. He thanked me for coming to his country and helping his people. It still shocks me how gracious the Filipinos are for humanitarian assistance. There are signs randomly strewn around town indicating such salutary sentiment.

It probably speaks to my cautiousness that I suspected the teenager to be a tout, which in most countries means he befriends you, shows an interest, tells you some facts and then asks you for money.

Not here. I walked around for an hour seeing the five or so boats that were abnormally hulking on land. Not once was I asked for anything. But the kids smile and yell out, and adults say “good morning” or some other greeting in a warm manner.

This is not a unique sensation amongst the staff, I’m finding. The consensus is that this is a kind, welcoming, and honest place. To underscore the point, I thought that I had left my cell phone somewhere the day before. I went back there with a local MSF staff fellow to help me translate, and he said something of the order of: “you will probably get it back, people are honest here.” Not since travelling in Japan have I found a place like that.

The contrast between life-as-usual playful staff and friendly interaction, immediately counter-posed with the evident destruction and loss of life in the typhoon, is hard to reconcile. It’s as jarring as a massive boat in the middle of the street. I’ve never been exposed to the aftermath of a calamity, but I did not expect the resiliency of the Filipino community to be this pronounced.

A small convoy of people were coming through the MSF hospital space, and I said hello to a man and woman.  They responded with an American accent on their English, and stopped me to talk. Turns out that they had Filipino heritage, but had grown up in New Jersey. They had donated some money to the project, and were coming by to see it.  The woman asked me if I had found a lot of PTSD (her word), and I stated that there was some, but less than I had expected. She said, “yes, we are very resilient.” A few more minutes of talking revealed that she and her husband were doctors, herself a psychiatrist. She knew from whenst she spoke.

There are always some clinical anomalies. Here, it seems that it is trauma-induced psychosis. This is a rather rare phenomenon, showing up for brief periods after rather extreme stresses on the body (lack of sleep, dehydration, sustained high stress). Often this occurs in persons with a vulnerability to psychosis (they have had bouts of paranoia in the past, during periods of high stress, substance use, or just spontaneously).  But I have now seen three cases which developed with seemingly no pre-Typhoon psychiatric history. In otherwise highly functioning people, frank auditory hallucinations and paranoia have developed post-typhoon. Common symptoms to all three involve hearing the voices of dead people, and thinking that someone is going to come and kill them. Family support, sleep, antipsychotic medications, and close follow-up have been effective, but the psychosis is lasting longer than expected. Something to ask the local psychiatrists about when I see them next.

Another odd thing. There is no word in Tacloban that I have heard that means “foreigner.”  Kids yell out “sankai” which translates to “friend.” While there may very well be one or more, it is notable that in two weeks of being on the ground, I do not know it. This is contrast with other regions that clearly demarcate in-group and out-group members. In Canada we have a unique politics of identity. It makes very little sense to say that someone is “not Canadian.” If I meet someone on the street or in the hospital and ask them where they are from, and they respond with the only three English words at their disposal: “I am Canadian,” I could very well smile and say, yeah, but where were you before here. Un-Canadian behaviour would be someone who was being unfair or culturally insensitive. The Canada I know seems to pride itself on being inclusive. Or, said differently, we have a rather weak politics of exclusion. The sense of inclusiveness here in the The Philippines is a marvel, and, if I can say, more pronounced than any place I have yet been.

33. Tindog Tacloban! – Intro

This blog is mirrored from the MSF site. Pictures are added. Date of initial publication: February 18, 2014. 

IMG_3386 DSC00342 DSC00415

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 answers to which may be of interest to some and not others. From conditions on the ground involving lodging, food and security on to the impact of physical and psychological trauma on the local population, and how the project is addressing these needs. Somebody asked me how I brought enough toothpaste for 2.5 months, given that I had a strict 10k checked-luggage weight limit. That’s ok. I’m posting this openly as others may be interested in what an MSF mission to the Philippines is like for a rank-and-file forensic psychiatrist from Toronto.

Happy reading, whoever you are. Your time is appreciated.

But please keep in mind that this blog is personal, and in no way is meant to represent the views or organizational values of MSF.  I wholly support the MSF that I know to be an independent, politically neutral organization that provides medical care irrespective of race, religion creed or political conviction.  If you walk in the door, and are in need of help, MSF does its best to help.  This is my third mission with this organization, and it is a pleasure and an honour to work with them again.


Human-caused climate change likely had something to do with the “super-typhoon” on November 8, 2013 that tore a strip off of regions of the Philippines. Winds of over 300km/h, and gusts well higher, made this the most powerful such storm ever recorded to make land-fall. And it did. It was as if not a single building was left standing in some regions, by reports, photos, and remaining carnage evident. Tacloban was one of those hard-hit regions.  A city of about 200,000 people, it is on Leyte Province, in the Visayas. I arrived on February 8, three months afterward the typhoon.

Filipinos are accustomed to storms with high winds, but this was something new.  Not only were the gale forces well in excess of the near-monthly storms that come through, it was the unexpected rise in sea level, 4 metres high in some regions, that caused so much loss of life and other damage. Tacloban is at the crux of an inlet, so the water brought by the typhoon was amplified.  The death toll is not clear, but it is over 7 thousand. Millions were affected.

MSF was on the ground in in the Philippines within several days, but as is the case in calamities, putting resources on the ground is only half the battle.  Distributing them is the other.  Infrastructure (roads, communications, water and sewage, power sources and lines) were wiped out.

The Wikipedia site describes the scene as follows:

According to estimates on November 13, only 20 percent of the affected population in Tacloban City was receiving aid. With lack of access to clean water, some residents dug up water pipes and boiled water from there in order to survive. Thousands of people sought to evacuate the city via C-130 cargo planes, however, the slow process fueled further aggravation. Reports of escaped prisoners raping women in the city prompted a further urgency to evacuate. One resident was quoted as saying “Tacloban is a dead city.”[61] Due to the lack of electricity, planes could only operate during the daylight, further slowing the evacuations. At dawn on November 12, thousands of people broke through fences and rushed planes only to be forced back by police and military personnel. A similar incident occurred later that day as a U.S. cargo plane was landing.[92]

 On November 14, a correspondent from the BBC reported Tacloban to be a “war zone,” although the situation soon stabilized when the presence of government law enforcement was increased. Safety concerns prompted several relief agencies to back out of the operation, and some United Nations staff were pulled out for safety reasons. A message circulating among the agencies urged them to not go into Tacloban for this reason.[93]

MSF has set up services in a hospital that was previously damaged.  They are fixing the structure so that is is usable and safe for MSF staff, and have hired many who were in its employ prior to the typhoon.  Functioning six days a week, they saw over 2500 patients last week in the outpatient department.  There are about 50 inpatients, which include surgical cases and maternity. Last week there were 57 admissions on the maternity ward, which was over capacity, so several new beds were added.  MSF provides free care and medicine,,so the numbers of people using our services are swelling.

I’ll be speaking about the mental health project more, but briefly, there are three components:

  1. Outpatient department (OPD): referrals from other services and our own follow-up
  2. Outreach: counsellors attend evacuation centres, hard-hit regions (baranguays) and other places where mental health needs are concentrated, and provide individual assessment and therapy on-site; we refer complicated persons to our OPD.
  3. School Program: Set up by child psychiatrists and psychologists, this ambitious project works with teachers and caregivers in elementary schools hard-hit by the typhoon.  Just to provide the scope of the destruction caused by the storm, one school which I attended last week had 63 students (30 male, 33 female; and one teacher) killed.  This was from a census of 430 students (grades 1-6) and 17 teachers. (Correction, there were 67 students killed at the school… the final count changed as more bodies were discovered since this number was first written.)

We have one psychiatrist, one psychologist, 8 counsellors and two translators.  Individual assessment and counselling are offered, which makes MSF, I’m told, perhaps the only NGO (non-governmental organization) to offer such services in the region.

When I was at the elementary school, the skies darkened and it started to rain. The winds picked up ever so slightly. A fright that I have never seen before en masse in children set in quickly.  They jumped up and huddled in the corner and cried; school teachers and our staff attended some of the more distraught ones.  One child ran toward her house, inconsolable.

It is hard to transition from such anguish.  But this post is to capture a brief snapshot of the project, and then return to mental health and some other issues more fully.

I’ve never seen an MSF project that was not ambitious.  This project is ambitious.  Some details.

There are, now, around 15-20 expat staff (like me who have been brought in from outside the country), and a much larger number of local doctors, nurses, midwives, pharmacists, etc. I should get numbers, but suffice it to say that this is fair-sized facility.

The logistics of putting so many supplies on the ground, navigating the decimated infrastructure, and arranging these medical services, is nothing short of staggeringly impressive.

Two quick examples.

The hospital’s electrical system was shot through when the typhoon hit.  In addition to the electrical grid in the city going down, and all the hospital damage, the water level hit the second floor of the hospital.  MSF rigged a complete second system of wiring and outlets within days of being in the building.

Second example: a few days ago I wrote on a requisition form that Mental Health Services (MHS) could use a flipchart and second whiteboard for teaching purposes, in addition to the markers, erasers and such that go along with this.  Within less than 24 hours, a flipchart and 2 paper rolls, as well as a whiteboard, were set up in our group meeting room.  The flipchart stand was constructed after the requisition was put in.  That this is seen as standard service is, I say again, hellava impressive.  Logistics is the unsung hero of MSF (at least from the outside; inside the NGO world and by all who work for the organization, their praises are sung).

The MSF project expat staff now live in a structure that used to be a hotel.  Everybody except for the 4-5 staff (surgeon, anaesthesiologist, midwife, obstetrician, emerg doc; they’re on call, so that’s the rationale) share rooms.  It’s a pretty swish location for MSF standards, with the local generator providing power for several hours in the morning and evening.  We have people who cook, clean and provide security, so food is pretty healthy and plentiful, the house is safe, and so on.

Most of the staff are out of the house by about 7am, and arrive at the hospital within 15 minutes or so.  We have several vehicles that provide transport, some of which are larger buses with open bench seating in the back, and more modest rickshaw-type units.  The end of the day seems to be around 5-8pm, depending on the need.  I’ve not left before 7pm, despite some messy jet-lag (it’s 13 hours ahead of Toronto).  This was not really my desire, but things have been busy.

So there it is.  I’m going to try and attach pictures, but internet is really spotty.  We don’t have it at the house, but seemed to have had it for several hours yesterday at the hospital… narrow bandwidth.  Not having internet is like having phantom limb discomfort.  You just feel like that appendage should be there.

It must be said early on that the Filipinos have been a warm, welcoming, and generally wonderful population with whom to work.  This is not the case everywhere, really.

OK. Toothpaste. I brought 50ml, assuming that since this was a large-ish city, I could find some here when I ran out.  This is true now, but for the first month that MSF staff were on the ground, this was not the case.  Finding food, clean water and other basics was a challenge for the first wave of MSF staff on the ground. I don’t know what they did.  An emergency relief mission is a different thing than what we’re doing now.  I greatly respect the efforts of the many staff (expat, local, distant) that carved out the project that allows me to fly in and immediately focus on mental health work.

À bientôt.

32. Tindog Tacloban! (link to MSF blog)


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

Screenshot 2014-02-19 15.57.54

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 … [Continue reading]

30. Correctional Psychiatry in Canada – Article


  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


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, … [Continue reading]

28. Darfur, Sudan – The Magic Quarter


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]

27. The withered buffer

When in Chad, I took notes and walked around with a Camera.  My mission was, in my mind, to help with the immediate concerns/suffering, to document, and to learn about a larger world with my feet in it.  Advocacy became more prominent than I would … [Continue reading]

26. “Reverse Culture Shock”

  It’s been about two weeks since I’ve been back, and I have not put my fingers on the keyboard.  There are a number of reasons why this is so, but the primary reason is that I want… to be more present, and the past half year is … [Continue reading]

25. In a Gentle Way


It would be fair to say that before coming to Chad, in the months leading up to this mission, I was expecting something alien.  Conditions and life-ways so extreme and dimensionally different from mine that I would struggle to connect with them.  … [Continue reading]