MSF Doctors Without Borders

37. Tindog Tacloban! – The School Program

April 23, 2014 By StevenCohen-CAMH

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.

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

April 12, 2014 By StevenCohen-CAMH

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.

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.

Filed Under: MSF Doctors Without Borders, Steven Cohen CAMH Forensic Psychiatrist Tagged With: Dr. Steven Cohen CAMH Toronto Forensic Psychiatrist

35. Tindog Tacloban! – The Outpatient Program

March 22, 2014 By StevenCohen-CAMH

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 travel.

Three counsellors. One of whom is an MD, the other two have an undergraduate degree in psychology. All have had previous training with another MSF project in the Philippines. We’re constantly bantering and discussing cases along the way.

First we attend Tanauan Central School Evacuation Centre. There had been a planned time for follow-up sessions with some persons identified as having difficulty adjusting to post-typhoon conditions, whether above the threshold for a diagnosis of mental illness or not. The tent city locale was empty. Almost completely empty, in that there were even no kids about, which is a rare thing out here. Turns out that the whole camp had gone to a place called Pago to work on the more permanent structures to where they would be moving eventually.

We moved on to a small displaced persons camp, mostly made of up tents. We met with the Captain of the local region, and he warmly greeted us, but advised that there was a food distribution going on, which clearly took priority over the planned psycho-education session that we had arranged. We rescheduled for that afternoon, and hopped in the Jeepney toward the next stop.

The Assumption evacuation centre was similarly empty. Again, the inhabitants had gone to Pago to work on the housing structures there.

So we decided to do the most expedient thing and headed to Pago. There was a single concrete structure erected, and the start of many others. Building materials were stacked up in neat, organized piles. Large groups of people were working on different projects: moving wood, cleaning metal beams, concrete mixing, brick-laying, etc.

The MSF counsellors split up to find the persons with whom they had follow-up sessions planned, and they retreated under the shade of a tree to do their work. If possible, returning to work is almost always a good thing. It aids with depressive and anxious symptoms, of which post-traumatic distress is included. Work tends to be social and provides a sense of purpose, worth, and community-building.

The housing units are provided in order of need, and there is an equation that takes into account the size of the family, number of children, destruction of property, distance from shoreline, and other factors. My small poll suggested that most people thought that this was fair, and that they wanted to move in as soon as possible.

Next stop lunch. We ate, discussed the cases, and planned the afternoon. Fish, rice, some meat stew that might have been pork. Like most prepared food here, there is too much sugar and salt. The fish was fantastic. The lunch room was a small open-air establishment that had been built mainly since the typhoon. On one side was the road with cars driving by, and on all other sides the visible debris from the storm. It had been arranged into piles of metal sheeting, wood that seemed to come from docks, and broken cars and other forms of transportation that had been destroyed. The region, Bislig, is one that was hard-hit, and is also being targeted by our Outreach team.

We then returned to Magay for that psychoeducation centre. A bell was rung and the milling-about crowd grew from 20 to over 100 persons. It was a lively group. Many mothers holding babies, some who had been born since the storm. The Barangay Captain, a white-haired septuagenarian fellow who wore crisp jeans and a jean-shirt, curiously unaffected by the blistering heat and humidity, introduced our team. The counsellors launched into their routine, which was in the local dialect of Tagalog, called Waray Waray. One of the counsellors translated some of the on-goings, but more than anything I was fixed by the cadence and energy of the group. It was fast, interactive, and thoroughly engaging to the participants. The group called out answers to questions, made comments that struck home to easy laughter, and asked for clarification if the need arose. It was warm and intimate. I want to write that it had this tenor “despite” the setting, which was a slightly shaded area, 20 or so seats, with the rest of the people standing. But of course, it had almost everything to do with the setting.

Psychoeducation sessions are necessary here. It is very common to have people brought to the hospital by family for non-specific or unexplained medical symptoms such as bodily aches, irritability, sleep problems, and decreased functioning in the social, family or work sphere. No mention of sadness and anxiety is made, but on inquiry, there is significant concern in these areas. There are also more cases than I would have suspected involving persons who have been psychotic for years, and were never brought to the attention of a mental health professional. Some teaching of common symptoms of mental illness, and the availability of free MSF services, is a good thing. Of course, one wants to be aware of local ways of expressing emotions and behaviours associated with illness (idioms of distress and styles of reasoning), as we don’t want to prime people how to “properly” exhibit illness. But it seems that even moderate to severe symptoms may go unrecognized and unattended to by available health resources. There is much more to say on this topic, but I’ll leave it there for now. Something interesting happened.

At one moment during the 20-minute session, one of the counsellors asked the group if anyone had a family member or someone close to them who was killed by Typhoon Yolanda. There were many hands that went up. Then someone made a comment that got everyone laughing, and some were looking at a 60-ish year-old woman who was in the front row. She laughed, turned a bit red from the attention, and then started to cry. She covered her face, but motioned that she was ok, and for the talk to continue. The counsellor went to stand beside her, put a hand on her shoulder, as had several others who were sitting beside her or standing near her. The counsellor continued the session, and after a few minutes moved back to a central location. When the session was over, the counsellor sat down beside her and they spoke for 15 minutes or so. There were about three or four women who had pulled up chairs to take part in the discussion.

It was explained to me afterwards what happened. The woman’s name was the international call-sign name of the storm, and her husband died in the typhoon. When the group was asked if anyone was killed by “Yolanda,” someone joked that she had killed her husband. I double-checked that I heard that correctly. It’s hard to imagine a large setting in which humour like this wouldn’t be off-side back home in Canada.

I work at a Toronto hospital called the Centre for Addiction and Mental Health (CAMH). It’s one of the largest mental health institutions in the country. I could not even fathom humour such as this being mobilized in this way, but I started to wonder what it would take. I’m still wondering.

Here in Tacloban city and environs, in this most remarkable of places, humour is used with great deftness in the integration of psychologically traumatic events in a coherent and tolerable narrative. This is healing behaviour. It struck me that this was a shining example of the concept of resiliency.

(The winds hit gusts of 365km per hour; many stores that have reopened include the name Yolanda.)

Filed Under: CAMH Forensic Psychiatrist, MSF Doctors Without Borders, Steven Cohen, Uncategorized Tagged With: Dr. Steven Cohen CAMH Toronto Forensic Psychiatrist

34. Tindog Tacloban! – The Boats

March 10, 2014 By StevenCohen-CAMH

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.

Filed Under: MSF Doctors Without Borders, Steven Cohen CAMH Forensic Psychiatrist Tagged With: Dr. Steven Cohen CAMH, Toronto Forensic Psychiatrist

33. Tindog Tacloban! – Intro

February 18, 2014 By StevenCohen-CAMH

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 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.

Onwards…

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:

Outpatient department (OPD): referrals from other services and our own follow-up
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.
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.

Filed Under: MSF Doctors Without Borders, Steven Cohen CAMH Forensic Psychiatrist Tagged With: Dr. Steven Cohen CAMH, Toronto Forensic Psychiatrist