35. Tindog Tacloban! – The Outpatient Program

jeepney inside (1 of 1)

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.

jeepney red (1 of 1)

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.

tent city

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.

tent city 2

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.

tree ripped up

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.

z 365 store

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


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, I get a slight rush of happiness when I get a ticket. 

uh… wha? 

Growing up in Thornhill, Ontario was a standard, Canadian, secular-cloistered environment.   When I started driving, at around 16/17, I would occasionally get parking tickets and feel hard-done-by.  When I was driving and heard sirens behind me, my stomach would drop.  Thankfully I never got a speeding ticket, but still, I recall the quasi-instinctive fear of the law. This feeling more or less diminished throughout my life, but the residues remained; tickets are a bad thing.

In Chad, there is no rule of law that is worth mentioning.   There was a local administrator in Farchana, and often I was trotted along to negotiations now and again as it was viewed as a sign of respect to bring medical team members to meetings.   The fellow could be abrasive and accusatory, and other times could be downright pleasant.  He could do whatever he wanted.  He had a type of power that is unknown in other parts of the world.  He could set the truth conditions for the world around him, if only a small chunk of the world.  That which he said was wrong was wrong, and his word was generally unquestionable.  Negotiations were delicate, to say the least.

This fellow casually stated one afternoon, during a meeting, that he allowed MSF to maintain its medical mission with relative safety.  Nobody doubted this.

During a car-jacking, as I mentioned in a previous post, an ex-pat humanitarian aid worker from France was shot in the head.  His death may not have been entirely accidental, and the repercussions for the local community was effectively absent.  This was a sanctioned occurrence, it appeared.

Harsh, arbitrary and radically discretionary punishments, meted out by the local warlord was the way of life.  Human rights were negligible.  Women’s rights were almost non-existent.  This was the furthest thing from a meritocracy I had ever seen, and it made me sick to my stomach.  It struck me for the first time how crucial the rule of law is to undergirding civilization.  (I wondered what other fundamentals were necessary and sufficient, such as payment of living wages, adoption of the scientific method, etc.)


Back to modern day Toronto.  The fact that one can leave their car for an extra 20 minutes for which payment was not made, and there is a surveillance system that is generally fair, universal, enforceable and contestable is a great achievement.  A seemingly small thing, but flowing from an absolutely necessary, and in a way, a wonderful system.  Even if I’m out $30 for tarrying a bit.

17. Tea-time at the non-sequitur café

hamraNote that none of the following pictures contain patients, and all parties have signed written consent to have their pictures included in this blog.  Of course, parents signed for les petits.


Not sure what it was that helped me turn the corner, but after a couple of feverish nights and a loose string of, well, phlegmatic days, some energy returned!  Whether it was the anti-parasite medications, a few long walks under the mango trees, good days at work, or the regime of sun salutations, vitality creeped back in.  You need it here, too.  In the same way that it’s hard to remember the summer heat on your skin in the dead of winter, after a trudge through the dregs I’d lost sight of the joy in many little things out here.  So I thought that this is what I’d write on, or just show.  The things that you do that make this place fun…

Steven Cohen Psychiatrist Patrice.nerds

My good friend Jerry sent me a few care-packages of junk food and sundry, which included a bag of ring-pops, some original star-trek cards (odd), bubble gum tape, pez, and nerds.  This is a picture of Patrice, eating nerds for the first time.

Steven Cohen Psychiatrist Jochen.rope Steven Cohen Psychiatrist me.rope1

Jochen brought a slack-line from Swabia, and we’ve been practicing our tight-rope walking on weekends.  Seriously, you you make this up?

Make a Ouaddai-tini:
1) Go to Eastern Chad, in the Ouaddai region of the Sahel
2) Find hooch (locally called “diable” or “demon”)
3) Mix it with home-made Hibiscus juice

Walk pretty much anywhere and get accosted by jovial screaming tots

Steven Cohen Psychiatrist boys.fox.1 Steven Cohen Psychiatrist truck_work Steven Cohen Psychiatrist Kids.tree

Play soccer with them

Steven Cohen Psychiatrist volleyball.1

Kidnap a wee malnourished goat, nurse it back to health for a couple of days, and set it back out with it’s kin.  Be told by one of your staff to never touch local animals because the rules of Chadian ownership of animals is “more complicated than sex between ducks.”  Look confused.

Steven Cohen Psychiatrist hanamai Steven Cohen Psychiatrist Hanamai.2

Relearn the extent to which necessity is the mother of invention

Steven Cohen Psychiatrist IMG_0599

Read while listening to Ivan playing guitar under the mango trees

Steven Cohen Psychiatrist Ivan.guitar Steven Cohen Psychiatrist Ivan.guitar.1

Say hello in the morning to Fatima, a worker at the Nutritional Center, and her twins, Safi, and Safia

Steven Cohen Psychiatrist K.S.S

Say hello to Habib and Hamra, some of our MHS staff

Steven Cohen CAMH IMG_2207 Steven Cohen CAMH IMG_2200 Steven Cohen CAMH IMG_2176 Steven Cohen CAMH IMG_2156 Steven Cohen Psychiatrist Toronto IMG_2146 Steven Cohen Psychiatrist Toronto IMG_2096 Steven Cohen Psychiatrist Toronto IMG_1996 CAMH Steven Cohen Hamra

 Wonder after unfortunate abbreviations, MSFH Psycho for psychiatry

CAMH Steven Cohen MSFHpsycho

Say hello to the theatre group.  This week they presented a little ditty on “family planning.”  Later I learn that Zakariah has three wives and 19 children.  He looked disappointed when he learned that I had none of neither.  You either laugh or cry.

CAMH Steven Cohen theatre.troup

Uh, hello-moto?

CAMH Steven Cohen tent.moto

Walk through the camp and happenstance upon a volleyball game.  Be given a prized seat and asked if you want to help officiate.  Politely decline.


Hang out with Bienfait in the Health Center.

CAMH Steven Cohen Bienfait

Eat some lunch with the boys

CAMH Steven Cohen boys.lunch

Marvel at the need for vehicle-Bling, Ouaddai-region style.

Steven Cohen Psychiatrist Toronto bike_2 Steven Cohen Psychiatrist Toronto bike_1

Keep on providing good health care for free

Steven Cohen Psychiatrist Toronto definitely Steven Cohen Psychiatrist Toronto thatch_thorns

Wipe dust off your computer screen when you post blog entries

Steven Cohen CAMH dusty.screen

9. Mental Health Services # 2

Steven Cohen Psychiatrist Toronto | gound.girls2 Steven Cohen Psychiatrist Toronto | IMG_2174 Steven Cohen Psychiatrist Toronto | IMG_1985 Steven Cohen Psychiatrist Toronto | CdS.MH2 Steven Cohen Psychiatrist Toronto | C.Nut.back Steven Cohen Psychiatrist Toronto | sm-team

There are three MSF project sites in Farchana: (1) the Primary Health Centre, located at the edge of the camp, is where maternity and basic medical care are provided; (2) the Nutritional Centre in the centre of the camp houses the Community Health Service and a Therapeutic Feeding Centre for malnourished children; and (3) the MSF compound, a fifteen minute walk from camp, that has an emergency night-clinic attached.  Mental Health Services works in both of the two centres at the camp.  They consist of simple wooden supports lined with plastic sheeting.  It may seem like a flimsy structure but it’s like a home away from home; a quiet corner of the busy compound where we sit, talk, work, and, if need be, see patients in the room next door.  Four years ago, when this MSF-H project was set up, flowers were planted outside and they are now blossoming lilac and pink.  It’s a small thing, but it’s nice thing. Little pleasures go a far way out here. The flip-chart in the corner—some large pieces of paper stapled to a cobbled-together easel—shows residues of past lectures on personality traits, stigma, Maslow’s hierarchy of needs (need to unpack this one in a place with no soap…), traumatic stress and it’s presenting symptoms, and so on.

Every morning at about 7:30am, the team meets at one of the two sites.  We say our good-mornings and everybody asks everybody else how they slept.  This is the custom, but there is a twist: you answer honestly.  I’m not sure when it came to pass in Canada that the expected answer to the ritualistic “how’re you doing?” was a near-guaranteed “good, you?”  You’d pretty much have to be bleeding out of your eyes before you ventured a “you know, not so hot today.”  But in the camp, people routinely say what’s bugging them, and the morning “how’re you doing?” custom can take fifteen minutes.  I know who’s got diarrhea, who’s feeling a chill from the cool night past, and who’s child has a mild fever that is worrying them.  It’s unexpectedly personal.  I find myself wondering how this could be brought into the Canadian mental health team environment, but then I realise, it is already there, but usually only in groups of 2 or maybe three people who know each other well.  Here the closeness exists to a team of 10 or so, precisely in part because of morning conversations like this.

After this morning harrah, four of the counsellors go off to the « Thé Rencontre » or “Chat with Tea.” This is where everyone is welcome to sit around with friends, to drink insanely sugary tea, and to banter.  All the while, the counsellors circulate, listen, and give their spiel on what mental health services are on offer. It’s a lovely idea, and even though it’s just a large open space with some plastic sheeting over their heads and a few rude wooden benches against the walls, everything changes when you’re sharing drinks. It becomes friendly rather than clinical.  (below is a pic of the corner of tea room, but not during the « Thé Rencontre ».)

Steven Cohen Psychiatrist Toronto | psych.room.corner