Adaptation of Community Based Rehabilitation in Areas of Armed Conflict
By William Boyce (School of Rehabilitation Therapy, Social Program Evaluation Group, Queen's University, Kingston, Canada)
Armed conflict and civil strife have affected over 40 countries world-wide in the last decade. The majority of these conflicts are in poorer countries, and the principal victims are from poor families and vulnerable groups that include people with disabilities. This article discusses how the principles of community based rehabilitation may be applied in areas of conflict, and the challenges faced in trying to do so.
Armed conflict and civil strife are widespread, affecting over 40 countries world-wide in the past decade. The majority of these conflicts are in poorer countries, and the principal victims are from poor families and vulnerable groups like women, children, persons with disabilities and the elderly. These groups cannot flee easily, are at greater risk of death and injury, and are less able to access needed rehabilitation services if needed.
In 1990, UNICEF estimated that 22 million people had died in 150 armed conflicts since the end of World War II. For every child killed by war, three more are seriously disabled, resulting in 14 million children who have been physically disabled or psychologically traumatized by war during the 1980's alone (1).
Landmines present a particularly complex problem for those concerned with disability and rehabilitation. In addition to restrictions imposed by landmines on transportation, agriculture, and water supplies, deaths and injuries from landmines have become commonplace in post-conflict societies. In Angola from 1980-1988, 10% of the population were either killed or mutilated by landmines. Half of an estimated 50,000 Angolan amputees were women and children. In Nicaragua from 1983-1986, 10% of all hospital admissions were due to war injuries. In Mozambique, there are an estimated 8000 amputees from landmines, while in Cambodia there is the highest concentration of amputees (1 in 240 persons) in the world (2).
Injuries caused by landmines have effects at several levels: as impairments, disabilities, and handicaps. Landmine-caused impairments affect entire body systems and are often the most obvious and measurable characteristics. These impairments include amputation, spinal cord injury, blindness and burns. Landmine-caused disabilities, on the other hand, are the loss of abilities that are normal for a person of a particular age and development. These disabilities include problems in self-care, ability to walk to school, or to perform work duties. Landmine-caused handicaps are really the deficiencies of a society in accommodating to people with disabilities. These handicaps include problems in earning a living, physical accessibility, social stigma and isolation.
In areas of armed conflict, unstable political allegiances, politicisation of service agencies, and lack of leadership can create distrust and an atmosphere of tension which reduces opportunities for strategic planning and networking in rehabilitation. Finally, a lack of appropriate rapid assessment and evaluation methods may either prevent adequate information gathering, or produce information which exposes multiple 'divergent' problems which only appear insoluble.
The Community Based Rehabilitation Response
In 1989, the Rehabilitation International/UNICEF Technical Support Programme conducted a review of the physical rehabilitation needs of children and women victims of armed conflict, specifically in Angola, Mozambique, El Salvador, Nicaragua, and among disabled Afghan refugees in Pakistan (3). The report identifies how war causes disability, discusses the magnitude of the problem, and directs attention to specific areas of concern (including accurate assessment needs, lack of trained personnel, culturally inappropriate concepts of disability, and unequal participation of disabled persons). The recommendations promote community based rehabilitation (CBR), research and prevention, attention towards women, children and mental disability, and the overall incorporation of disability issues into international aid programs.
Community based rehabilitation represents a response, in both developed and developing countries, to the need for adequate and appropriate rehabilitation services to be available for a greater proportion of the disabled population. Many factors have stimulated this "community oriented" perspective of rehabilitation, paralleling the "primary health care" perspective within medicine. These factors include escalating health costs, inequitable distribution of resources, a limited rehabilitation workforce, increased consumer awareness and resultant demands upon health care and social systems, reassessment of the emphasis placed upon high technology and institutional based care, dissatisfaction with the hierarchical medical system, and a critical analysis of health determinants. While these factors are common to many countries, within developing nations CBR is used to reach the tremendous numbers of persons with disabilities who have limited or no access to rehabilitation. Only 1 to 3% of persons with disabilities living in developing countries who require rehabilitation services receive them, these services being particularly inaccessible to the rural majority (4,5).
What exactly constitutes the principles of CBR is the subject of much discussion. The World Health Organisation Expert Committee on Rehabilitation contrasts CBR with institution - based and outreach services of rehabilitation (6). In CBR, there is a large-scale transfer of knowledge about disabilities and rehabilitation skills to the people with disabilities, their families, and members of the community, such that resources are available at the community level and rehabilitation is "democratised" (7).
Helander (7) highlights the founding principles of CBR as being equality, social justice, solidarity, integration and dignity for people with disabilities: Community based rehabilitation (CBR) is a strategy for improving service delivery, providing more equitable opportunities and for promoting and protecting the human rights of disabled people... .It calls for the full and co-ordinated involvement of all levels of society: community, intermediate and national. It seeks the integration of the interventions of all relevant sectors -- educational, health, legislative, social and vocational -- and aims at the full representation and empowerment of disabled people. Its goal is to bring about a change; to develop a system capable of reaching all disabled people in need and to educate and involve governments and the public, using in each country a level of resources that is realistic and maintainable.
While Helander promotes a systemic view of CBR, Werner (8) proposes two goals of rehabilitation at the community level:
To create a situation that allows each disabled person to live as fulfilling, self- reliant, and whole a life as possible, in close relation with other people;
To help other people -- family, neighbours, school-children, members of the community - to accept, respect, feel comfortable with, assist (only where necessary), welcome into their lives, provide equal opportunities for, and appreciate the abilities and possibilities of disabled people.
Werner stresses the importance of persons with disabilities themselves being leaders and workers in rehabilitation activities, of meaningful work and training for persons with disabilities, and of local resources being used for rehabilitation equipment. Rehabilitation International and the UNICEF Technical Support Programme (9) support this view in asserting that CBR is based on a community development concept of individuals with disabilities becoming empowered to take action to improve their own lives and become contributors to society.
It has often been stated that there is no blueprint for a CBR project. This is because countries, regions, and communities vary enormously with respect to their administrative structures, economic and cultural conditions, distribution of populations, and financial and workforce resources. Each of these conditions must direct the nature of the approach to rehabilitation if the program is to be indeed "community-based". However, circumstances of armed conflict may overlie these conditions and drastically affect CBR's implementation. A co-ordinated CBR approach may contribute a great deal in addressing the issue of disability in these situations, however it may also be ineffective if improperly designed without taking principles of peace-building into consideration. Experiences in a number of situations of armed conflict (Palestine, Bosnia, Afghanistan, Sri Lanka, Central America) suggest that CBR has a constructive role to play.
Adaptation of CBR in Areas of Conflict
Overall, CBR means utilising community resources, involving persons with disabilities in the planning and education of rehabilitation personnel, focusing on psycho-social, economic, public attitudes, and educational integration issues, in addition to the usual needs for therapy, assistive devices and home support. The development of CBR programmes in areas of conflict has varied depending on the specific location. For example, in Bosnia, where there was a highly developed infrastructure for rehabilitation prior to the war, the aim has been to orient the re-construction of the entire system so that a CBR approach is utilized. In Afghanistan, where there was little rehabilitation prior to the Soviet invasion and little interest in rehabilitation by successive governments, the aim has been to develop a critical mass of basic trained personnel across the country (10).
CBR programmes in areas of armed conflict typically aim to reinforce the capacity of institutions and community agencies to work with other agencies that are active in emergency aid and re-construction, and which are often the only functioning organisations in the country. CBR programmes usually focus on: clinical services in remote areas; personnel training; promotion of Disabled Peoples' Organisations; planning, management and co-ordination; and appropriate technology.
However, the 'key elements' of CBR should be adapted in areas of conflict and thus have the potential for contributing to the process of peace-building (11).
Promotion of Positive Community Attitudes and Behaviours Towards Disability
CBR usually involves an effort to de-stigmatise persons with disabilities, often through promoting particular disabled persons as positive role models. In areas of conflict, such as Afghanistan and Sri Lanka, CBR facilitates school integration of disabled refugee children and supports alternatives to institutions for disabled, displaced, and orphaned children. In Palestine, health and social development program personnel are educated and encouraged to avoid preferential treatment of persons injured in the Intifada. This helps to reduce inequities between injured combatants and civilians and has led to gains for all persons with disabilities which previously had been difficult to achieve (12).
Empowerment of Persons with Disabilities Enabling their Integration Within Society
Development of disabled persons' organisations is a common CBR strategy and is best done by persons with disabilities themselves, preferably those with experience in politically dynamic situations. In Cambodia, Afghanistan, Mozambique, and Lebanon, Disabled Peoples' International consults to national disability organisations to improve their abilities to develop self-help programs and to conduct advocacy with their governments to improve local rehabilitation efforts. Meetings are being organised for persons with disabilities and the public to discuss the needs of disabled persons. This strategy utilises disabled persons' status and visibility as victims of war to achieve benefits for other disabled persons. Legislative and bureaucratic measures which include persons with disability in public services have become symbols of equality in Palestine. In Afghanistan, disabled persons' organisations have been linked to national planning. Organisations from different Afghan political factions are linked in common causes such as International Disability Day on December 3.
Knowledge and Skills Transfer to Promote Self-Help Skills
Skills transfer is a fundamental principle of CBR. Standard CBR training focuses on child developmental disabilities, polio, blindness, and stroke. CBR training modules for conflict areas also focus on major traumatic musculo-skeletal impairments such as head injuries, multiple fractures, peripheral nerve injuries caused by projectiles, traumatic amputations from landmines, and torture injuries. In Sri Lanka, joint training in CBR practices for both Sinhalese military and Tamil community groups is exposing different factions to commonalties of the disability experience and is promoting mutual assistance in the field. Such co-operative training between factions can be only achieved during windows of opportunity and must be acted upon quickly before separate, and possibly divisive, rehabilitation services are established for different groups.
Development Of Rehabilitation Services/Resources Based Upon Needs Identified By Persons With Disabilities And Their Families
Service development often involves conducting a disability prevalence survey and detailed needs assessment. However, CBR programmes in conflict areas prioritise action over lengthy planning processes. Rapid community-based assessment and evaluation methods for physical disability and psycho-social trauma have been developed to assess disability needs and local response capacities (12). Rapid disability assessment teams are necessary for emerging war zones such as Central Africa.
Community Decision-Making, Implementation, and Accountability to the Community
Community involvement is supposed to be routine in CBR. However, in post-conflict societies, communities are often divided. In Sri Lanka, community reconstruction has attempted to include disability access, and in doing so has required relocation of public services such as transportation and recreation facilities. This relocation has to be done with particular sensitivity or there is a risk of increasing tensions within ethnic communities which are suspicious of losing access to these services.
Models of Partnership and Co-Operation Among Persons with Disabilities, their Families, the Community, and Rehabilitation Personnel
Partnership is a core practice in CBR and involves communities in training local rehabilitation workers ('Training of Trainers' model), developing appropriate technology, and conducting needs assessment and evaluations. This type of co-operation can be extended to include national groups previously in conflict. In southern Africa, inter-country programmes bring together former political adversaries for policy, sports and cultural exchanges and have demonstrated possibilities for reconciliation.
Development of Rehabilitation Technology Utilizing Local Skills and Materials
Local technology development in CBR ensures sustainability. Emigrants from Nicaragua are also being mobilised to donate rehabilitation equipment, prosthetics, and orthotic supplies. In areas of conflict, local technical support persons (e.g., carpenters, welders) are sought, prior to training new technicians or developing new orthopaedic workshops. This approach is reinforcing support for community economic development in Angola which can assist those in their former homes.
Co-Ordination with, and Referral to, a Network of Specialised Interventions, Including Institutions, to Provide Professional and Technical Support and Training Which May Be Unavailable Within the Community
The referral element of CBR ensures that the community is supported by other technical agencies. In areas of conflict and widespread disruption, such as Central America, national development programs (primary health care, food and agriculture, rural and urban re-construction) are being integrated with CBR programs so that the needs of persons with disabilities, including ex-combatants, are considered and there is less exclusion. Organising national and regional conferences for CBR information dissemination, networking, and strategic planning demonstrates the benefits of a multi-sectoral approach to planners as they gain insight to the complex interaction between disability, education, and employment.
There are two issues in particular that CBR has yet to address in areas of armed conflict. First, CBR programmes often rely on women as workers, as volunteers, and as responsible family members. Eighty percent of all caregivers for persons with disabilities are women, and this figure is probably even higher during war (13). Expecting women to assume community based programme responsibilities may be an extra impossible burden. Women in conflict zones have little time available for CBR training. Furthermore, since they earn lower incomes, female-headed households may have little money available for rehabilitation equipment or transport to rehabilitation services. Strategies to support women's involvement in CBR must be found which do not make their lives worse.
Secondly, the problem of large numbers of disabled ex-combatants, who are generally young men, must be addressed by CBR since they represent an on-going reminder of conflict to their communities and thus a source of friction. Demobilisation and re-integration support programmes (including assistive devices, referrals, home activities of daily living (ADL) training, social and peer support, vocational training, income generation, leadership development) are vital to de-fuse tensions and demonstrate society's ongoing respect for injured veterans.
CBR programmes that address the multitude of serious impairments, disabilities, and handicaps in areas of armed conflict present substantial challenges to rehabilitation professionals. Practical and political obstacles are ever-present and must be addressed with foresight yet a certain amount of luck is also required.
The benefits to a CBR approach in conflict areas include not only addressing the needs of persons with disabilities as a critically vulnerable group, but also include important contributions in: facilitating groups working together; in demonstrating a multi-sectoral approach to problems which require interaction and negotiations; and in preparing the way for health and social sector reforms when the conflict subsides.
- UNICEF. The State of the World's Children 1990. New York: Oxford University Press, p.3, 1991.
- Roberts S, Williams J. The Enduring Legacy of Landmines. Washington D.C.: Vietnam Veterans of America Foundation, 1995.
- Rehabilitation International/UNICEF. Effects of Armed conflict on Women and Children: Relief and Rehabilitation in War Situations. One in Ten, 10 (2-3), 1991.
- Helander E, Mendis P, Nelson G, Goerdt A. Training in the Community for People with Disabilities. Geneva: World Health Organisation, 1989.
- World Health Organisation Expert Committee on Disability Prevention and Rehabilitation. Disability prevention and rehabilitation. WHO Technical Report Series, 668, Geneva: World Health Organisation, pp.7-37, 1981.
- Helander, E. Prejudice and Dignity: An Introduction to Community Based Rehabilitation. New York: United Nations Development Programme, Division for Global and Interregional Programmes, 1992.
- Werner D. Disabled Village Children. Palo Alto, California: The Hesperian Foundation, p.14, 1987.
- Rehabilitation International/UNICEF (1989-90). Community-Based Rehabilitation: A Ten Year Review. One in Ten, 8 (1-4)/9 (1-2).
- Coleridge P. Disability and culture. Chapter in press
- Boyce W, Ballantyne S. Community based rehabilitation in areas of armed conflict. Presented at the 8th World Congress of the International Rehabilitation Medicine Association, pp. 65-69, 1997.
- Ballantyne S. Community Based Rehabilitation Under Conditions of Political Violence: A Palestinian Case Study. MSc thesis, Kingston, Queen's University, 1999.
- Boyce W, Weera S. Issues of disability assessment in ware zones. In, B.Holzer, A. Vreede and G. Weigt (Eds) Disability in Different Cultures - Reflections on Local Concepts, Bielefeld: Transcript-verlag, 1999.
- Eade D, Williams, S. The Oxfam Handbook of Development and Relief. London: Oxfam Publishing, 1995.