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, treats and risk-manages, aiding those with mental illness in transitioning back to the community.   But this post is not about the job.  It’s more about reflecting back on the missions, some years past.

First, a bit about Sudan.   About three months after returning from Chad, in mid-2008, I was asked to join a mission in Nyala, Sudan.  Kalma Camp was, at the time, the largest refugee camp in Darfur, and some said that it was the largest in the world, with about 150,000 internally displaced persons (IDPs).  It was a troubled time, of course, but another emergency had reared its head.  The sitting president was being investigated for charges of war crimes of the worst kind, up to and including genocide.  He had been tolerating humanitarian aid in the country because to not do so looked pretty bad.  Well, in the wake of the impending indictments, he decided that such bad press was the least of his problems, and he was moving to kick all humanitarian aid projects out of the country, and mental health was going to go first.  The mental health staff speak to people, and in gathering stories, so the presidency was concerned, might collect information that would be injurious to his human rights record.

I was only to interact with MSF staff, and have no direct patient contact.  No journalism of any kind.  No cameras.  No notes were to leave the country.  Any transgression would result in being jailed.  This was made very clear to me, and I signed several Arabic language documents (which my translator struggled to explain).  My translator impressed upon me that even suspicion of wrong-doing is enough to be jailed.  And Sudanese jails are the stuff of nightmares.  These people were not fucking around.  Blogging was, of course, verboten.

So MSF needed a psychiatrist to go in ASAP and work with three local doctors on matters of assessing, diagnosing, treating and managing persons with schizophrenia.  There was a small and closing window, so to save time, MSF sent me to Nairobi, Kenya to try and get a Sudanese visa more quickly.  It took some doing, but a week later I was on my way to Khartoum.

The worldwide prevalence of schizophrenia, fairly consistent across all ethnic and social strata, is about 1% of the population.  So in a camp the size of Kalma, one would estimate, all things being equal, that there would be about 1500 persons with this endogenous psychotic disorder.  But that’s a big assumption, the equality part.  The political situation was, to put it mildly, chaotic.  Surviving a dangerous situation, especially a protracted one, takes great organization, stamina and resolve.   Vulnerable populations such as the elderly, children, and persons with physical or mental deficits, are less likely to stay alive without support structures in place, and these very structures were being torn apart by the violence.  It was impossible to state how many persons with schizophrenia were in the camp, but the project had about 200 persons for whom they were providing regular care.

If you want to do emergency psychiatric work, and get the most immediate, profound and potentially enduring benefit for the population, there are many strategies. One of them that should be included is to find the schizophrenic population and, in consultation with their family or other supports, offer low doses of antipsychotic medication.

Steven Cohen CAMH | haldol

Medication is the single best intervention for schizophrenia, and while it does not cure, it controls many symptoms quite well in a large percentage of the treated.   Haldol, an older and well-established medication, was available in large supply, and was available on the open market (through pharmacies; no prescriptions are necessary in Sudan).  Of course, MSF had its own supply chain, and the medications were of the same standard as those provided to anyone in Canada.  But while emergency and relief humanitarian aid does the best it can, and for a whole host of reasons, a person with schizophrenia or their family may need to access antipsychotic medications in the future and not have access to an established clinic, and thus it is very helpful to have a medication that has a local supply chain.

Haldol (or haloperidol) is still used regularly by Canadian psychiatrists, although often for more acute psychosis accompanied by agitation and aggression.  It is in the Canadian guidelines for medical management of schizophrenia.  The well-worn prescribing mantra of “start low and go slow” fit the situation.  Most of the persons with whom mental health staff have contact in Canada are well known to the system, and have been tried on one or more antipsychotic agent, and usually in high dose and even in combination with another medication.  In Kalma Camp, by contrast, almost every person treated was neuroleptic-naïve, which meant that they had never taken a medication of this drug-class.  Haldol came in 5mg increments, and to allow for some sort of standardization, we cut them into quarters (1.25mg per piece) and started there.  Avoiding side-effects while getting the best effect with the lowest dose was the goal, as it always is.  And it turned out that 1.25mg, twice a day, was the optimal strategy.

One day a fellow with schizophrenia was brought in by his family for follow-up care.   He had been started on Haldol before I arrived in the camp, and I was seeing him at what might have been his “best baseline” or mental status at his best treatment level.  I’ll call him Abdul, although for the life of me I can’t recall his name…  I kept no notes, something that was prudent, but most regrettable nonetheless.  Abdul was in his early-20s.  His family provided most of the history: Abdul started exhibiting psychotic symptoms (the harbingers of what would become fully blown schizophrenia) in his mid-late teens.

While he was once gregarious, athletic, and sociable, he became more reserved, isolated, and unable or unwilling to engage in basic behaviours such as maintaining hygiene, social protocols and schooling.  Unfortunately, he also developed strong paranoia, and believed that his brother was trying to do him harm.  About two years prior to when I met Abdul, he became aggressive, and killed his brother.  His family recognized that he was ill, and was not to be punished, but they had to contain the risk, and chained him to a log.  Abdul could move slowly from one place to another, and was cared for by his family as best they could.  The family found antipsychotic medication in the marketplace (the pharmacy medications, likely of purer provenance, were too expensive), which had some beneficial effect, but not consistently so.  The family heard of the MSF project, and travelled between camps in order to find treatment for Abdul.  He had been treated with MSF-provided antipsychotic medication for about a year prior to my having seen him.  Abdul was pleasant, conversant and fairly engaging, albeit somewhat emotionally detached, and he mainly answered questions that were posed to him rather than speaking spontaneously.

He was well-dressed, living with his family, and was taking part in the family business.  He was betrothed to be married.  Abdul recalled little of the incident leading to the death of his brother, and his family jumped in and explained that this was not the “real Abdul… it was the sickness in him.”   Abdul recalled being chained to a log, and while it was deeply unpleasant for him, he recognized on some level that his family was acting in his best interests, and he did not appear to harbour any resentment for it.  He indicated that he needed the medication to stay well, and that the “magic quarter” had saved his life.  I agreed that his family and the magic quarter (of Haldol) had saved his life.  The status of the MSF project was in jeopardy, and the Abdul and his family were understandably quite worried about what would happen if the free medicine became unavailable.  They were provided with a solid supply of the medication.  To this day, I wonder how Abdul is doing now.

The structure of the day involved waking up early in Nyala, eating a perfunctory breakfast, and hopping on the “landy” (Land Rover) that took 45 minutes to get to Kalma Camp.  The bench seats in the back were simple wood planks, and six or eight people would cram in.  The terrain was rough.  I had tweaked my back (degenerative discs are not kind to the aging), and could feel the bumps.  We’d arrive at camp, and I’d head off to meet with the three local doctors.  We spoke in English, but also had a translator for some of the trickier concepts.  We saw patients with their families all day, and made time for a lecture over the lunch-hour.  One after the next, each doctor would take turns assessing, presenting the case to the team, proposing a treatment strategy, and then discussion and implementation.  This happened as many as 20 times a day.  Rough and ready guidelines flowed from these discussions, and they were translated in Arabic.  MSF encouraged the guidelines to be distributed widely, and many photocopies were left with the Sudanese doctors.

By the end of my two months, the three doctors were not only managing this population well, but were holding their own lectures for other staff, and training what would be their support staff for the continued clinic.  It was a resounding success.  I was elated, proud to be a small part of MSF and the mission.  And it felt like something new, something that I resolved not to forget, as it is so easy to.  I was not a simple cog in the machine out there, but a part of something larger than myself in which I had a crucial role.  I was part of something that would not have taken place had all the elements not been in place.  There was a type of satisfaction in this work that does not often come from other types of work.  It was brief, meaningful, and nourishing for that core of the self for which we have so many names but nothing concrete.

Steven Cohen CAMH | Us.Stock



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 have expected.  In some way, the writing and documentation probably also served an anxiety-mitigating function… intellectualization takes you out of the moment, a bit.  But that was a fair trade-off.

Having returned, though, I have this aversion to taking pictures.  I can be in them, I can want to preserve moments in time, but I don’t carry a camera (one was in my pocket for six months) and have a slight pang of guilt for this.  I wonder what my new Chadian friends will think if they saw photos of me in Canada.  This is foolish on many levels, but the object of this thread is not to be rational and prudent, but to be descriptive.  A photo seems to me a wish to preserve, and I have nothing to add.  My giddy and smiling nephew and niece are rather well photo-documented already… I just play with them and field questions about mud, carrots, monsters and stuff… I like that.


Casual cruelty.  There is a concept in psychiatry called “over-kill” or “casual cruelty.”  When a guy gets in a “fair fight” in the bar or wherever, and he hits his opponent who then falls over, he stands back.  The fight is done.  If the guy continues to kick and punch and inflict damage, pain and suffering, then this is deemed aggravated assault, and it can happen for a few reasons. I’m not really going to get into it, but the desire to see others in pain is bloody well endemic in our society.  TV shows such as The Sopranos, Criminal Minds and Dexter, all runaway hits, reflect this desire in us to be exposed to this cruelty.  I say experience not in the sense that anyone wants to carry it out.  Not at all.  But to my knowledge (and I’ll admit that I’ve not done any research into this, but I’m guessing that there are more than a few PhD theses written on this very topic), Tony Soprano is the “good guy”, albeit a complex character.  I don’t know when I have ever been cajoled by television into wanting to character identify with a psychopath (again, made more complex in that he is a pro-social one; Tony stands up for Italian culture, family values, community safety, etc).  Dexter is a more striking example.  He only goes after baddies, but the gore, the sadistic drive, and the absence of empathy are there in great part.  Criminal Minds trip over themselves to depict evil in a more provocative and disturbing form each week.

It is too much.  I used to watch them, and now I choose not to.  In one sense, the duty to withstand negativity, psychologically challenging emotions, and disgust, are necessary for a psychiatrist.  Our duty, as is the duty of many other professionals or philosophers alike, is to see the world for what it is, and pay attention to appearances when the mind wants to look away or self-protect.  In some fields this is called “negative capability,” but I think that I am using this term in the Bionian sense (As in Wilfred Bion).  I used to think that I had a high negative capability, but it turns out that the exposure to so much suffering in Chad has worn this out.  My buffer is still thin.

I watch the television, an escape for me that lives on, and while I used to revel in the psychological twistedness of the characters, and their undoing, now I find it banal at best, and usually aversive.  Sure, there are bad people, and they don’t care about others, and some of them are truly callous and perverse.  But the majority of suffering in this world is due to neglect and indifference.  Chad’s government doesn’t give a fuck about their people.  They just don’t.  They would kick every NGO out of the country if it weren’t for the risk of losing aid money and IMF and other assistance.  This is a country that wanted to tax MSF for the medicine brought into the country that was being dispensed FOR FREE.   Right now, to me, the face of evil is the face of the man behind the desk that made that decision.


Six Feet Under, now that is a good show.

I’ve been back for over a month now, and the fatigue has mostly lifted, I’m getting back to being skinny rather than mildly alarmingly rakish, and the humour is starting to come back without me pretending.   I seek out fun, rather than trying to be a part of it for mainly the sake of distraction.  I think a lot about healing.  The pragmatics of healing psychological distress.  I think about closeness and caring, and the vulnerabilities that this engenders.  I am thinking about connection-making and breaking.  The ties that bind and the ties that keep us from moving on.

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 hauntingly ever-resent.  The very morning I awoke for the first time in my bed in Montreal I received a message from the clinical coordinator in Amsterdam asking me if I was willing to go to the Sudan.  It turned out that the government is kicking out the NGOs for a host or reasons, and there is a need to train local doctors how to continue treating persons with schizophrenia and bipolar disorder.  Good work, and very necessary.  I wanted to go, and I ached to say yes.  But my body was depleted, and I sheepishly wrote back that given my commitments to various hospitals (locum contracts that I had set up), I could not go.    It was true, but I also knew that I was not ready to return the next day.  I didn’t know what I needed, but there was a need that I had that could not be met in Darfur, and I would not have been able to do a proper job.  I sadly declined.

Needs.  Forgetting a very healthy thing, and sometimes is an efficient means of processing.  I once came across a fellow who had served in the army in a war-stricken land, and I asked him the usual questions to see if he had post-traumatic trauma: re-experience with physiological and psychological distress, hyper-vigilance, and numbing, to name a few.  He had what I would consider a healthy, normal pattern of behaviour, and a healthy, normal constellation of sadness, fear, and loathing of the negativity of the experience.  He told me about his buddies who had been diagnosed with PTSD, and his eyes welled with tears.  I asked him what his thoughts were about how he had avoided that, and his answer surprised me:  “I came back, I went on a two-week bender, and when I came out, I just put my head down and worked hard.”  Let’s be clear, I am not advocating this.  That moment has never left me, though.  Forgetting, as Théodule Ribot wrote in his Maladies Des Mémoires, is one of the boundaries of the self.   If you can’t remember, you’re hooped.  And in a surprising way, if you can’t forget, you can be hooped, too.

Omar Khayyam once said something like “I drink not for mere love of wine, nor to scoff at faith, but only to forget myself for a moment, for that alone do I drink.”

I didn’t quote this to the veteran.  Alcohol is a very bad medium- or long-term solution.  The line that kept coming to my mind, and what we did discuss, was the phrase about smelling the roses, the implication being that if you stop and smell the roses, you smell everything else as well.  Another phrase comes to mind, again I don’t recall who said it, and I am fighting the urge to be academic and look it up.  It lauds “the hard moral work of remembering.”  Yes.

OK, academic diversions aside.  Now.  How am I now?  The staccato sentences mirror my thought process.  I am tired, and have to sleep in the afternoon still… this is fading, but for a week, it was consuming.  My capacity for social interaction is growing, but too many people in a room is exhausting.  The memories of close friends in Chad, especially Issakha and the counsellors, are vividly fixed in my mind.  In psychiatric parlance, I have trouble code-switching.

I am home, wherever that is.  Eating well, sleeping in a safe land and a comfortable bed, and caring all around.  My friends and colleagues are in Chad, listening to heavy artillery, fearful that the fragile stability could break at any moment.   I miss them, and feel for their situation, and the powerlessness to change much of it.

Now.  What is it like now?  Like a faraday cage, where the sounds and smells all seep in, but I am walking around in a haze.  Sparks of stimulus on the periphery.  Like an overexposed picture, my quasi-detached consciousness in the centre.  The sound of cars is disturbing me more than makes sense.  I cannot switch from thoughts of Chad to thoughts of my life… “where are you?” a few of my friends have asked.  “Just catching up on sleep,” I return, and hope that the playfulness in the tone is enough to keep from more prying or concerned questions.   I don’t want to talk about it and have the topic changed.  Sometimes I walk away.  I’ve never done that before.  One of the few things that a psychiatrist never says (or should never say) is “too much information.”  But I find I need to walk away.  My buffer is thin.  My resources have been taxed.  I’ve been working again.  Jumped back into the hospital life, and it has been very busy.  The nurses tell me I look gaunt, and it’s true.  When I look in the mirror, I wonder how I had 15 pounds to lose, but it went somewhere.  I feel like I’m communicating with some barrier in between, like there is an isthmus between me and the mainland of the world I used to be in.  It is a weirdly detached feeling.  Sometimes it goes away, and I enjoy that.  Other times I wonder how long it was like this before, and I never knew.

25. In a Gentle Way

Scz.flipchart red.road orb.steppes.2

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.  In anthropological parlance, I exoticised the other.  This is almost never a good thing.  It is also somewhat inevitable, at least when exploring new terrain, however much you try and keep it in check.  In order to minimize the anxiety of the unknown and unexpected, we start entertaining possibilities.  Like mythologies and daydreams, they have no direct correspondence with reality, but these animated exhalations are good to think with.  Like a mental jungle-gym.  The problem is not in doing this.  Quite to the contrary, exploring hidden assumptions and their entailments are the scaffolding of psychotherapy.  Or most any insight-oriented activity, really.  Rather, the problem would be in affording these guesses, assumptions or projections a stability that does not reflect their arbitrariness and self-soothing origins.  In the first post that I wrote, I asked some semi-rhetorical questions:

How can a psychiatrist WWHUUMMP parachute into central Africa and expect to do anything useful?

*Tense sigh* These people have suffered such incomprehensibly intense, sustained, and unpredictable trauma, and the situation remains horrendous!! What do you say to a person who has lost his or her family, community, and livelihood?! What do you say to the woman who has been repeatedly raped when going out at night for firewood, and will continue to do so because her children will die without cooked food?! What do you say to say to a child who has been orphaned, neglected, and abused?! What can a psychiatrist do?!?

Both questions are of the same form: what can a psychiatrist do when he or she has no clue how to connect with unfamiliar circumstances?  The uncertainty was palpable—and sensationalistic. [Read more…]

24. Pretty Pebbles

I want a Porsche.  There’s no way around it.  Ever since I was a kid cars have fascinated me, the power, aesthetics, speed, engineering.  My jaw kind of drops when I see one, and has for many years.  I’ve had my eye on an early 90s 911.  The guy who designed this car, Erwin Komenda, is a genius, inspired by turbulence reduction, drag coefficients and rocket ships.  And, at the risk of being improper, rudimentary polling indicates that the golden number for the price of women’s “must have” shoes hovers at $300.  Listen for the choir: “more for boo-oots!”  Whether or not one actually buys these things is not the point.  What I’m trying to  do is reconcile such desires with where I am.

The pen in my pocket (easy fellow Freudians…) is a Uniball extra-fine.  Black, made in Japan, a triumph of mass production and injection-molded plastic.  In Canada, it costs about three bucks, which, incidentally, is about a days labour for an unskilled tradesperson in Farchana.  It is also the price of a beer here, of which you have your choice of two local brands or a bottle of Guiness.  How’s that for distribution networks?  Kids here ask for money occasionally, but most often ask for a cola or a pen, the latter being called a “bic.”  Pens have currency; this is a place where most people do not have one.  Where the “prized seat” is a plastic garden chair, even when dealing with the highest levels of local official.  In the capital, N’Djamena, there are five-star hotels, a parliament building, and a court-house (that’s in construction).  Otherwise, it is shanty-town.  On the same block, in all directions.  From the pool area, you can hear hammers smashing away at fallen concrete structures; people are salvaging the steel rebar inside to sell to scrap-metal merchants.


In Farchana, the people with money have meat in their food and a plastic lawn-chair at their disposal.  Those without may forego a few meals.  There is no such thing as a Vegetarian outside the expat compound… the idea of passing on meat for ethical or aesthetic concerns is unimaginable.   Not that it’s a failure of imagination, it is just unheard of. [Read more…]

20. Logistics, nimbly

Steven Cohen Psychiatrist store.room

Much of the work that we do out here is focused on the final act: the prenatal exam, the psychotherapy session, the assessment, diagnosis and treatment of disease, supplements and monitoring for the malnourished. In a very real sense, the good people in Berlin and Amsterdam support the administrative Country Management Team (here in Abéché), who in turn support the logistics arms of the many projects all along along the eastern border of this godforsaken land. And they, in turn, support the medical people. Us nurses, doctors and midwives are left with the task of patient care, pure and simple. Food is on the table, pantries full, land-cruisers to transport, medical centers running triage, pharmacies stocked, electricity flowing, water delivered.

Steven Cohen Psychiatrist plumpy.mozzy Steven Cohen Psychiatrist U.med.stock Steven Cohen Psychiatrist bechir_stock

Organizing anything in Chad is no mean feat. This is a place where no opportunity for misunderstanding goes unexercised. Where negotiations often start with a stalemate or a threat and progress from there. Where everybody is needling and clawing for money and kickbacks. Where the security situation hangs over you like a thundercloud in the distance; you never know when it’s going to break.

I wrote a couple of weeks ago about the murder of Pascal Marlinge, the Head of Mission for Save the Children (StC). That day, all NGOs stopped providing non-essential services and retreated to the safety of their respective compounds. StC, understandably, never resumed. Within a week it was unofficially known that they would, again understandably, suspend all their activities and most likely leave the country. This left Breidjing Camp, with 30,000 refugees and 12,000 local IDP Chadians with no organization providing medical care. A vacuum.

Steven Cohen CAMH Breidjing Steven Cohen CAMH brick_pits Steven Cohen CAMH morning.convoy Steven Cohen CAMH base.A,pic CdS.hamlet1

This is the story of how MSF took over services and within two weeks, were up-and-running at full capacity.

People. Jochen, our mobile clinic nurse with many years of field experience, stepped up to the Project Coordinator position (PC). With a solid handle on both the medical and logistics side of things, he hit the ground running and hasn’t stopped since. Jean-Marc, the technical logistician also stopped on a dime and headed that way, as did almost all the national staff on the mobile clinic team. Ivan, our PC here in Farchana (but he basically likes to do everything, and would if given half the chance) got to planning. Since ground transport has been declared unsafe, Breidjing would need an airstrip. Ivan called up Karline (our Head of Mission in Abéché) and asked for authorization to build one. On the phone, at that moment, she said yes, and within two days 159 local workers had been hired and were on the job. Within six days the first flight landed and took off, notably bringing Ivan back to Farchana.

Steven Cohen Psychiatrist Toronto fox.convoy Steven Cohen Psychiatrist Toronto chariots Steven Cohen Psychiatrist Toronto plane.plumpy

A full complement of staff were hired and given contracts. Stock rooms were inventoried and new medications and supplies ordered. Endless meetings with local authorities, and long conversations into the night about what to to the next day. It was, as Ivan calls it, “E-team mode,” which stands for Emergency-team. If there are locks on doors and you can’t find the keys, you cut the locks. You don’t think of overtime costs for national staff, you just work till the day ends (although notably none of the staff even asked for extra pay). Administrative authorization lagged behind implementation. Often. The lines of communication were open throughout, but decisions were made on the ground.

Notably absent from this story is the call for funding. In most organizations, it would take months of proposals and oversight to fund a project that effectively costs about a million Euros a year to run. It’s an onerous, paper-heavy task, leading to what could best be described as administrative fatigue. MSF, however, is independently funded. This means that beforehand they do not need to knock on government doors, UNHCR doors, or whomever, to ask for the means to provide health care. There is minimal lag. The airstrip, which incidentally had been “in the planning” for three years, and was built by Ivan et al. in five days, cost about 2000 euros. This is the cost of doing business out here. Health care for a population of 42,000 people for a whole year. Fantastically reasonable. In my view, administrative fatigue is rather low in this organization. Every cent is accounted for, of course, but money in MSF, at least from my vantage point, is not a “power-grab,” it’s just grease. My guess is that everyone over the age of six knows how rare this is. It likely would not escape the purview of an astute six-year-old, either.

Steven Cohen Psychiatrist Toronto HAH.lunch CAMH Steven Cohen dramatroupe3 CAMH Steven Cohen dinner CAMH Steven Cohen sm-team Steven Cohen Forensic Psychiatrist  jidomobile Steven Cohen Forensic Psychiatrist  Giuliana_Paule

I include the numbers because they interest me, and I figure others may want to know as well what things cost. Money is important.

This is a proud moment. (I was on vacation, so I feel justified in beaming without seeming the least bit self-congratulatory.) On the day that Pascal was killed, Ivan, Jochen and Edith (our logistics administrator) sat under the mango tree and spoke about what it meant for them to work out here. It hit them hard. But the conversation went from personal reflection to planning. What if StC left Chad? What would need to be done to keep primary health care services in Breidjing. It had to be MSF. Literally, nobody else could do it, given the administrative fatigue of other operations. They sat down with paper and pencil the next day and started mapping it out: a proposal to make it happen ASAP, for about two to three months, until a long-term solution could be found.

Group identification is a funny thing. I hear people all the time saying of their favourite football, hockey or basketball team that succeeds: “we won!” This is absurd. In the words of Chris Rock, a comedian, “no, six black guys, who would hate you if they knew you, won.” This is not absurd. But it does highlight the extent to which people ignore every register of class division and common sense to feel associated with something winsome. All of a sudden my friend who works in a bank, from a sheltered, privileged and rather sanitized petit-bourgeois childhood is character-identifying with Shaquille O’Neil. “We won!” Pointing out the absurdity does not mean it shouldn’t happen. Personally, I don’t care one way or the other, it’s mostly just amusing. But it does tell us something. That we want to be a part of something bigger than us, a community, a team, a movement that means something, that does something of which we can be proud. People buy products because some pretty face or talented athlete endorses them. And even the humanitarian world is on this: I see the faces and read the words of cinema- and rock-stars on the plight of those suffering oppression and its hardships all over the world. And why? I’m not arguing that it’s not pragmatic, but it’s strange, too.

I see many faces of MSF, but for me, this week, it is Jochen, Ivan, Edith, and Jean-Marc (three of whom, incidentally, are Canadian). They did not win a football match, nor have they been shortlisted for an oscar nomination. But they did work non-stop for two weeks to fill the vacuum, to enable the provision of emergency health services in a large refugee camp in Eastern Chad. No newspapers picked up the story, of course. Can you imagine what would happen in Montreal if medical services were stopped for two days? What about two weeks? It would topple governments. It would be a national state of emergency. Well, it’s an emergency here, too, but look who did something about it. My team.

Steven Cohen Forensic Psychiatrist  team

19. Zanzibar, Tanzania, Africa

CAMH Steven Cohen fox.base

The ground moves here.  It may look like a patch of dirt, rubble or cracked concrete, but it you crouch down and just wait a few seconds, it starts moving.  Tiny ants doing reconnaissance, larger ones lumbering through, smaller red insects that look like pin-point spiders everywhere. Long things with many legs, beetles, and others start to circle and weave along some hidden meshwork that is beyond the understanding of humans.  Or maybe it is just random, chaotic radiation, turbulence, Brownian motion.  Scurrying like white noise.  There are no straight lines in Africa.

CAMH Steven Cohen crystal.spikes

I write “Africa” in the sense that most people that I have met use it here. Chadians will refer to themselves as Africans, as will Sudanese, Tanzanians, Kenyans, Congolese and so on.  It does not escape the Chadian pastoralist that he has a vastly different language and life-way than his neighbour in the next town, the village up, or over the lake yonder.  The word “Africa” resonates as a whole for the people who use it, and this is remarkable.  A few words of Arabic or Kiswahili, and millenia of trade, land rights, marriage arranging, brotherhood brokering, animal husbandry and herding, water-balancing.  These forces stretch a continent.

Shift ahead a few days.

A small place called Bwejuu.  South-East coast of Unguja, the main island of the Zanzibari archipelago, itself just off the coast of mainland Tanzania.  It was a seaside town, that forgot to close down, and moved at about that pace.  I’d arrived in the trough of low season, but met a few similarly wayward travellers nonetheless.  By day three I felt that if I was any more relaxed I’d slip into a coma.  Which was nice.  My mornings were spent snorkeling through the fringed coral reefs, and I awoke to the sound of small yellow birds that make small teardrop-shaped nests in the trees all around my bungalow.  Jeremiah, one of the Masai fellows working at the small guest house at which I stayed, asked me if he could take my motorcycle (250cc of Honda Baja glory) to the beach and ride it.  He had the energy and smile of a gleeful person, which struck me as a strange quality in someone carryone no fewer than three concealed blades under his flowing red garb.  As we went out to the beach, I realized that he had never ridden a bike.  But hell, neither had I until a week ago.  The problem came in trying to explain what a clutch is with twenty shared words!

Zanzibar is called The Spice Island, which is a misnomer. Sure, it may have once been the hub for trade in cardamom, lemongrass, nutmeg, chili and peppercorn, among others, but the food is of the blandest I’ve ever eaten.  Luckily this is well made up for, among many other things, by the spectacular views.  I had not bought a new camera by then, so I’ll just have to describe the scene.  Rough-hewn locally made tables on a white-sand beach.  Low-light candle in a corner.  The sun sets quickly and leaves a blotted underbelly of fiery reds and purples on the clouds.  It looked like hell upside down, and from a safe distance.  Lateen-rigged dhows are off in the distance, small wooden fishing boats that have a triangular shaped sail with a scythe-like curve that is masted close to the front of the sliver of a vessel.  Every image was charmed… that kind of a place.  I looked over to the right of me while I was sitting out there and saw about eight other people on the beach, seven of whom were taking photos.  This is a well photo-documented generation.  It struck me that it may be the case that more photos were taken of sunsets that one day than in all of the 19th century.

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My days on the island were coming to an end, though, and I had to run back to the capital, Stone Town.  This is, incidentally, also not really a meaningful moniker.  I suspect that it would have been more accurately called Smelly & Cracked-Concrete Town, but alas, that did not track well with focus groups.  The point, though, is how it is that one finds their way around this island, back to the capital.

These were the directions: “Turn right at the T-junction, then left at the second round-about, past the big “Foma” detergent sign, and when you’re close to town, you’ll see an intersection that looks like a platypus… turn hard left there…” and so on.  I was becoming a bit frustrated… the lack of street signage makes it difficult to know where you are, and where you should be going.  Over the past week, with no real destination in mind, this had bothered me none.  I had my rented dirtbike, miles of road and beach, and, of course, throngs of people everywhere to ask directions along the way.  And this is when it struck me… that image.  The one that comes at 5am, wakes you up, and just sits there.  You know the type, no?

Back a few nights.

Imagine a hard flat surface like a book or open hand slapping forcefully against another surface, that of a placid body of water.  Scale is unimportant.  Look at the streams of water that are jetted out from the sides, shooting outwards but connected by small tendrils, some thick and goopy, others impossibly thin.  A viscous crown of molasses-like mesh, curving in all directions.  Like in networks of veins just under the skin or on a leaf.  Patterns on wind-swept desert sand.  The mesh of a sponge.  The petrified pith of trabecular bone.

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This was the road back to stone-town, and the people were the network along which I would wind my way.

It started to rain, and I pulled over under the metal sheeting of a small hut where kids were selling fruit.  My clothes were soaked through, but it was warm enough to ward off the chill.  I bought a large papaya and ate the reddish-orange pulp while chatting with the kids in some broken pidgin of English and my ten Swahili words.  The boys were fascinated with the multitool leatherman that I had used, and took turns over the next two hours passing it among them opening and closing every knife and screwdriver.  Despite the rains, lots of bikes, motorized and not, whizzed by.  I waited for the rain to stop, pointed in one direction and said “Stone Town?”  To which the boys smiled and nodded yes, trying to curve their hands to the left, which was what I had to go on.  There are no straight lines in Africa.  But with a belly-full of papaya and the hot sun drying your clothes, this seems less important.

18. Power

The day that I left Chad a text message arrived an hour before hopping on a plane for my holidays (I write this from idyllic-but-obviously-not-too-distant Stone town, Zanzibar). The text message said that a fellow named Pascal Marlinge, the Head of Mission for an NGO (Save the Children, UK branch) had been shot and killed in a car heist a short drive from Farchana.



It left me sad and a bit numb; I write this with heavy hands.  I found myself trying to make sense of it. How could this have happened? And, inevitably, why did this happen? Why would someone shoot a clearly unarmed person exiting a clearly marked humanitarian vehicle with his hands in the air? And this is where my mind has gone while sitting in airport terminals, eating street food in the grungy Escape-from-New-York backdrop of Dar es Salaam’s Kariakoo district, and watching the waves foam up on shore.

The word that I keep coming back to is “power.” Several years back, one of my mentors in psychiatry casually said “there is only one type of power.” I am not sure if he’s right, but he’s the type of person that you listen to, and figure out how they came to that conclusion, even if you’ll disagree with it eventually. Over the years I’ve muddled around with the question of what it would be, this one power, if there was just the one. And what I’ve come up with is this: power is the ability for one entity to set the viability conditions for another. That is, one entity can effect a gross difference in the capacities, choices, and mortality of another entity. For humans, this would include, for example, a parent or state feeding their young so that their bodies can grow and learn; teach skills leading to more vocational choices; or the provision of basic health care so that a premature death doesn’t cut this potential all to shreds.

It is also, notably, the power at the end of a rifle, an apron string (families excommunicating members), an emotional outlash.  Images of tyrants always come to mind when I think of “powerful” people. Mussolini, Mugabe, Stalin, Pol Pot, Mao Zedong, Nikolai Ceausescu, Saddam Hussein. Basically what these guys did was whatever the fuck they wanted, and nobody could say otherwise. They were, and are, barbarians.

Lust, gluttony, avarice, sloth, wrath, envy, pride. These are the seven deadly sins, which may as well be a laundry-list of the manifest entailments of 20th century Western success. “Get rich or die trying.” Envy was used in the sense of “malice” in the fourteenth century, as in “creating equality” be taking or destroying that which someone else had… the vulgar side of jealousy: hate someone for having more or being more.

But this is here it gets complicated. I think that most of my cohort can rally against the despots, but what of the seven sins? It may be schlocky, but I think that TV is a sophisticated barometer of an ethos. While practicing up in the Canadian North, I had too much free time and a satellite connection, so I watched all seven seasons of The Sopranos. Hellava good show, and to my mind, there has not ever been a character as complicated as Tony Soprano. Somewhere along the way (maybe in the second season), I realized that this guy was a simmering psychopath (however pro-social). Enter “Dexter”, another TV character, who is a blood-lusting psychopath who “uses his evil powers for good,” killing “bad” psychopaths. Brilliant premise, but can you imagine the pilot being pitched twenty years ago? Not a chance. For 50 years, the bible of broadcasting was the Production code of motion pictures, and for 40 years or so up until the late 60s, it stated that:

“No picture shall be produced that will lower the moral standards of those who see it. Hence the sympathies of the audience should never be thrown to the side of crime, wrongdoing, evil or sin.”

You couldn’t even watch someone pretending to be evil!  As if just the perishing thought could shift the balance to the dark side.  I remember being timorous in medical school when I asked patients if they had ever had ideas of suicide or self-harm (a standard part of the psych exam, and for good reason). It was hard for me to ask the question, as I did not know what I’d do with the answer, or worse, that I’d throw their symathies to such an act.  It’s kind of absurd that someone’s going to say “wow, suicide, great idea! Never thought of it, but you’ve been a great help, doc.” I needed to gain experience with the idea of suicide in the same way that I have needed, in Chad, to become more familiar with ideas of genocide, mass displacement, and wanton violence the likes of which I had only read about, but never seen.

But what do we do, then, when we character-identify with Tony Soprano in some way but are also revulsed at the mindlessness of actual wanton destruction and death? This is not a rhetorical question. We talk about it, and the dialogue makes it more real. There is no answer, of course, but exploring it carefully may lead to a better ability to balance the essential urges of war and peace that wage their quotidian battles in us. Maybe we’ll even gain a better understanding of what power means to us, and use some of those superpowers for good.

So what, then, would be the luminescent side of power… how can we counterpose and salvage the beauty in willful and benevolent expressions of it? It would then be the exercise of might in capacity-building, the prolonging of life and heightening of health, all in the service of preserving the right for people to choose what they want to do. If freedom is some waffly continental breakfast, options and choice are the sustenance that sticks to your ribs.

MSF came out with a position paper of sorts called “The Chantilly Document.” It starts with a single line, before getting into two pages of text:

“The overall purpose of MSF is to preserve life and alleviate suffering while protecting human dignity and seeking to restore the ability of people to make their own decisions.”

In my opinion, Pascal was doing this. He was working away from his wife and two children, in an inhospitable place, quite likely for less pay, less stability, and higher job-related anxiety than he could have found elsewhere. Like so many people that I’ve met out here, they hold it together for some reason or another so that, in the long run, others will have more options. This character trait I call integrity, the exercise of which is strength.

It is apalling the abuses of power that I have seen in the past several months. The stories, the lives, the wounds physical and psychological. They track closely with the absence of wide, transparent, and consensus-driven means for accountability. With no accountability, it seems that power prevails over strength.

In the end, Tony Soprano got punted by his Shrink.  Strength prevailed after seven seasons:) I hope that Farchana does, too. We’re in our fifth year, now.


sorry, no pics.  My camera broke.  The fellow at the repair shop said “There is a lot of dust in here, where have you been?”

    “Chad, four months.”


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…

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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.

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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

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Play soccer with them

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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.

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Relearn the extent to which necessity is the mother of invention

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Read while listening to Ivan playing guitar under the mango trees

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

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

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 Wonder after unfortunate abbreviations, MSFH Psycho for psychiatry

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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.

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Uh, hello-moto?

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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.

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Eat some lunch with the boys

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

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Keep on providing good health care for free

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Wipe dust off your computer screen when you post blog entries

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16. Fruit in a Bowel

“It’s not the mountain that wears you down, it’s the rock in your shoe.”

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It has been brought to my attention, most unceremoniously, that I have kept the blog more descriptive than personal, more playful than ranting, more academic than grit. That I’m telling the stories of others more than telling my own, and am committing the error that every shrink hates to make, but invariably does: I ask everybody else what they feel about this or that, and am not asking myself this question (or at least not writing about it). Point well-enough taken. How am I doing? Right now I’m starting to feel better, but last week I felt mostly flat, tired, and shitty.

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When I arrived here among the standard questions I received (age, length of stay, number of wives and children, etc.) was “have you ever been to Africa before?” And even though I left when I was three years old, my having been born in South Africa was met with a genuinely warm inclusiveness; I was told that I have, and will always have, “un coeur d’Afrique,” or an African heart. I don’t know why, but somehow it fits in a goodly way… I feel a corporeal kinship with the soil, steppes, and people. The words “South Africa” smell of Jakaranda trees in blossom, of my grandparents’ Johannesburg flat, and large platters of freshly cut fruit. My bowels, though, are assuredly Canadian, and have for the past several months been treating me like an angry, antibiotic-crazed prostitute. And you can imagine that my skin, incubated for the past 20-some years in the halogen havens of classrooms and hospital hallways, feels about the same.

The rest of my body is, at times, not so thrilled either. After being here a month or so I got some odd rash on my palms, which I was told was probably from the harsh soaps or maybe dyshydrotic eczema (from sweating too much). Either way, over the following couple of months the skin hardened and then peeled off, but I was just glad that it wasn’t itchy anymore. Some problems with bed-bugs, a painful tooth (for which I went to the capital to see a French dentist who never arrived, so I just came back to Farchana), and some back pain rounds out my list of gripes. No, add the large spiders (like the size of your fist), the fact that a few weeks ago my computer broke (hence no pics on the last few blogs), that the MSF-provided shared computer has a screen that flickers epileptogenically, and that my blog is being censored in ways I don’t understand, and you get some sense as to the frustration. If I were back home, I’d get the computer(s) repaired, take a long walk, catch a movie, rant in-person to the censor, read a dour blurb in The Economist and promptly forget about it, partake of a soul-soothing smoked-meat Schwartz’s combo, paint, and sit across from a good friend or two and, while a smile and beer endure, sing the blues.

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For the first time since arriving, I felt tired in my bones last week. It’s been three months here, and I have since mostly marveled, but I recently found myself wanting to not have a 6pm curfew, not live in a 43ºC-in-the-shade dust-bowl, eat some standard fare, crap normally, and otherwise read for a week. I awoke one morning and felt *hesitant* about going into the camp and seeing patients. The crush of suffering was daunting, and I just wasn’t sure if this would be the day that I’d lose my grit and have to go back to the compound, or, dare the thought enter, just leave altogether. Worse still, that the empathy buffer was too thin and I’d show frustration with my patients or colleagues. Everybody has parts of their job that are uniquely hard, and for me it is working with children. It’s a cliché, I know, but the children save you out here (followed closely by your team and patients). I spend a lot of my day playing with tykes who initially yell out “ok!”, “ca va?” or “donne-moi un cadeau.” But when they’re mute and catatonically frightened after some horrific incident, it stays with me in a way that other patients don’t. Images of Fatna sitting on the mat with a perplexed and curious disposition still arrive in my sleep, when I walk from one health center to the other, or sit down to eat; her story, and so many like it, of the sticks and death, isolation and fear, are present.

I’ve always felt that it is a good thing to follow dreams, in part because they’re inspiring, but mostly because they never give you what you think they will, and you get a whole lot else in the bargain. Sometimes good things, sometimes less so, but it’s definitely good to figure that out sooner rather than later. This isn’t a nod to jadedness… it’s just what one finds when you pay attention to the appearance of things. And so it has been coming out here, to Chad, to Farchana. Last week, in the icy clarity of a protracted and jittery malaise, I started to recognize the pleasures that have been earned by the boys playing soccer with long-destroyed balls or the frustration in the eyes of an old man who knows his children will not be brought up in a political state that could in any way be confused with a meritocracy. Hope is an emotion that operates in accordance with the law of gases: it will expand to fit any container in which it is put. Last week I felt it to be thin, and I wondered, selfishly and somewhat ashamedly, how I would survive in this rarefied environment. If hope is some ether of self-preservation mixed with motivation, it is icy clarity and rage that focuses it like a lens. This helps… to know in that vital way that things here need to get better. It counters the adaptive instinct that can bring with it a well-intentioned but eventual complacency. Well, that and another course of antibiotics that hopefully will get the bug that ails me:)


About 5 years ago I was living on the plateau in a cavernous unfinished loft on St. Laurent, a couple floors above a bar/billiard hall called “Le Swimming.” The place comfortably slept five; at that time there were seven. The plumbing had been done by my buddy and loft-mate Adam who was a master of approximation and invention when it came to fixing things around the apartment. But with all the engineering capacity at his non-negligible disposal, the plumbing in the bathroom needed a better system than the rusty nozzles and showerhead. So we hopped into a beat-up MG that had recently had it’s entire bowels removed and put back in, and head off to where we could exchange money for said necessary product. The guy at the store showed us some pressure-balanced gizmo that adjusted hot and cold water in one nozzle—I’d imagine almost everyone reading this has one. But myself being a first-year psych resident, and Adam being in the throes of an interminable PhD in biomedical engineering (he recently finished, incidentally, and is off to MIT for a hopefully less-interminable post-doc), we decided to hit the hardware store and make do with a cheaper, non-rusty but still-crappy system. This is when the guy in the store, overhearing our conversation, said “don’t buy anything that’s not pressure-balanced, you won’t be happy with it.”

Fast forward to last Tuesday in the mobile clinic, about 25 miles southwest of nowhere, 7 pm, pitch dark on one side of the starry-night horizon, and opposite the last remnants of a faint under-lit glow just visible behind the mountains in the West. The shower was, as are most things here, built with an economy of resources and time as much as plastic sheeting and irregular-shaped bricks and crumbly mortar. So there’s the shower, a pillar of bricks in one corner of an open-roofed, plastic-sheeting-enclosed space slightly bigger than a phone booth. A black jerry can with a refilling hole cut out of it’s top sits on the head-high pillar, and a 2L plastic water bottle has been grafted onto the side of the can, with a rudimentary plastic spigot to adjust “water flow.” The water still hot from the day’s heat, I found myself wondering if the skin on my arms was dark because of the sun or the layers of dust and sweat and more dust. I think it was the best shower that I ever had.

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When did I forget this? That it’s not some fancy nozzle that makes a good shower. It’s being dirty after an honest-days work. If but only to learn that again I would have come back to Africa. Tomorrow is Monday… a new week and I’m happy to be here, but I suspect that I’ll also be well ready for that vacation that’s coming at the end of the month.