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.
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.
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.
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.
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.
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.
“Sherman saw three ghosts and he was scared of ghosts. He stays in the house to stay away from ghosts.”
“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”
“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.”
“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.”
As the weeks have passed, and the students in need of individual attention decrease, our program is coming to a close.
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.