Disabled Afghans in the Cross-Fire of Cultures
By M. Miles (m99miles@hotmail.com)
"An Afghan brought his severely disabled son into the Mental Health Centre, Peshawar, in Pakistan. Glaring at the school principal he began, in Pushto: 'I carried this boy on my back from Kabul. It took me two weeks. So just don't tell me that he is rubbish to be thrown away'." [C.Miles]
This Afghan father's perseverance, truculence, and anticipation of negative responses from the world of professionals, are not atypical in families with disabled members during the past two decades of turbulence in the region. This man trekked the barren road from Kabul down to Peshawar during the 1980s, among some two or three million refugees who left their country while the Soviet Union was trying to impose its own order and cultures on Afghanistan. Now in October 2001, disability service professionals in Peshawar are again reporting their rescue missions to collect Afghans injured or disabled in the bombing, who have managed to get as far as the border. Those who reach the comparative safety of Pakistan will find local services severely stretched by the latest wave of refugees - but they may at least be within reach of food and water, shelter and some skilled help. The great majority of disabled people who remain inside Afghanistan are once more reliant on their own and their families' meagre and dwindling resources, as the few scattered disability services are overrun by the tide of conflict.
Estimates
The number of disabled people inside Afghanistan is unknown, and high estimates are being bandied about with a view to fundraising. Based on local surveys, the chief technical advisor to the Comprehensive Disabled Afghans Programme (CDAP) suggests that, "3-4% of the population of 20 million is disabled ... about 700,000-800,000 people in the whole country. War injuries (mainly from mines) and polio account for about half of this number." [1] Better arithmetic would make these figures 600,000 to 800,000. The "20 million" population is an extrapolation from 1979 census data (when 13 million people were found), with further probable error. Yet the figure of 800,000 is now the 'official guess' [2]. Roughly half the Afghan population is under 18 years, and a quarter of all children die before reaching 5 years [3]. A further hazard is that some 300 square kilometres of land containing minefields and unexploded bombs needs clearing in 'high priority' areas alone [4]. The number of people disabled by mines is estimated by Abdul Rehman Sahak, who lost both legs and an arm to a landmine, at "over 400,000" [5]. This too is probably based on half of the dubious 800,000, regardless of the low survival rate of people with severe blast injuries in the harsh and unhygienic conditions of rural Afghanistan. A WHO assessment also suggests that "2% of the Afghan population" are blind, giving a figure of "400,000 people suffering from blindness", many of them from operable cataracts [6].
Services
Beyond all doubt, the number of disabled Afghans who could benefit from formal rehabilitation services has vastly exceeded the resources available at any time in the past 20 years. In the early 1990s several field surveys were carried out by an experienced paediatrician and development agent, Bengt Kristiansson, of resources in the capital Kabul and the provinces of Takhar and Wardak, before setting up the Disabled Afghans Project (1993-1995) with Swedish aid. Kabul, with a population of possibly 2 million, had a small number of institutional resources for physical disability, such as the Wazir Akbar Khan Hospital physiotherapy and orthopaedic departments, the International Committee of the Red Cross/Crescent Rehabilitation Centre, the Physiotherapy School, Indira Gandhi Pediatric Institute, the Afghan Red Crescent Society, and some manufacturers of wheelchairs, crutches etc. For blind people, the International Assistance Mission ran a blind school and sheltered workshops, while the NOOR Institute provided eye surgery. This level of services, inadequate though it was for the population, was much higher than could be found elsewhere in Afghanistan. Takhar and Wardak had a few general hospitals, but there seem to have been no specialised disability services [7]. Kristiansson commented that the concept of disability was always linked to war injury, especially amputation. Enquiry about which disabilities were common was understood to mean 'how many amputees are there', and other disability categories were considered uncommon. Disability among women and children was practically invisible, and adult male informants mostly reported that there were very few cases.
Whatever may have been available, and whatever its accessibility to women and children in 1991, ten years later few of the formal services still exist. Recent reports state that "surgical services in Afghanistan are weak or nonexistent. Former specialist medical units such as eye and hearing hospitals and plastic surgery have closed as a result of war" [2], and services to blind people have also closed recently [6]. Some community rehabilitation centres established by CDAP are believed to be still functioning in various parts of the country, though access for women and girls is severely restricted. Once again, the great majority of disabled people are thrown back on their own resources and those of their immediate neighbourhood.
It is important however for concerned foreigners to understand that although the situation of disabled Afghans is extremely difficult and the country's health and education services are severely limited, especially for girls and women, there is nothing intrinsic to the Afghan people and their cultures and beliefs that makes such problems inevitable. During the 1970s, considerable progress was made in developing a basic health care service across the country, and this was broadly welcomed and participated in by the people, as documented in detail by the Management Sciences for Health team which advised and monitored the process [8]. The cultural histories of Afghanistan also show that there are positive resources for enabling disabled people to play their part in community and society.
The Resource Heritage (briefly)
"Ehsan is the next higher stage after Adl in the Quranic social order. Ehsan means a condition where an individual lagging behind in spite of his best efforts gets his deficiency made good by others to restore the disturbed balance of society. This is not by way of charity but as a matter of right." S.A. Wadud, The Pakistan Times, 28 March 1986.
What follows is only the briefest sketch of some indigenous cultural resources on which Afghans can draw when it comes to reconstructing their country in a way that makes better provision for disabled people. Afghanistan was an East-West crossroads of the classical world. Long before the arrival of Islam, some knowledge of the scientific and therapeutic discoveries of the great civilisations of China, Buddhist India and Greece was carried across the present Afghan territory by merchants, itinerant healers, diplomats and armies. The Gandhara civilisation, extending across half of present-day Afghanistan and Pakistan, had the University at Taxila as its centre for medical and surgical training. Detailed orthopaedic knowledge was taught there, as in the Sanskrit Susrutasamhita. Medical knowledge also spread northward and eastward from Greece, to which Afghan hakims still trace their ancestry. This knowledge would have included the Hippocratic view that epilepsy was not 'sacred' nor a matter of possession, but a disease to be treated by careful observation, adjustment of diet and environment, and certain drugs.
Later, when Islam carried the torch of knowledge and development throughout the Middle East and Central Asia, the enlightened measures for treating mental illness were also known in Western Afghanistan. The civil rights of mentally retarded people and the legal permission for deaf people to give evidence using sign language were familiar from the widely used Hedaya, al-Marghinani's 12th century codification of Islamic law [9]. Medical therapies of the 16th century appear in the diary of the dynasty-founding Babur (1483-1530), who launched the invasion of North India from Kabul, his favourite city. From personal experience and observation Babur mentions various ailments, disabling conditions and remedies, e.g. arthritic joints, weakness and stooped posture, blindness of one eye; drip-feeding for loss of voice; his own youthful crisis of sexual orientation and his mother's tiresome exhortations; a smashed bone and (supposedly) orthopaedic surgery; trepanning for head injuries; opium for his persistent ear pain; no treatment for his dislocated thumb, but 'Qur'anic therapy' and various medicines for his fever (probably malarial); and the attempted 'exchange' of illness from his son to himself [10].
Much useful disability-related information has thus been known by some people at various points in Afghan history. However, the knowledge and therapeutic skills have seldom been institutionalised in the best sense - very little has been recorded in permanent form, and there seems to have been little or no transmission of knowledge by formal training of practitioners. Local healers have passed on their skills to their sons and daughters, but the transfer has seldom been monitored for quality, and there have been no mechanisms for expanding and testing knowledge and skills.
Some blind Afghans achieved good standing in their communities. In an authoritative work on Afghan history, Louis Dupree shows a photograph of a blind singer of epic poetic history accompanied by a blind musician; he also mentions a blind storyteller and records the lengthy rule of Khurasan by Shah Rukh, who had been blinded at an early age by a rival [11]. Another traditional occupation for the blind man has been to memorise and recite the Qur'an, taught by the local mullah. There was a well-established view that the blind person can become a 'community bank' of poetry, knowledge and skill, and may become a distinguished teacher. Certainly, some less positive traditions also exist. The Pakhtun view of the blind man's helplessness appears in the cynical proverb, "The blind man entrusted his wife to God". Other proverbs give disabled people a troublesome rather than a passive role: "The blind, the deaf, the scald-head, the paralyzed, wherever they sit, cause quarrels". [12] Some of these views persist among disabled people. At a meeting in the late 1980s to discuss the start of an association of disabled Afghans, two physically disabled men were dismissive of an elderly blind man who was present. "He's a blind! He can do nothing!" (They were unaware that he had been a senior academic at Kabul).
People with physical disabilities may traditionally have been perceived in a different way. Serious physical trauma, loss of a limb or paraplegia, would often have led to death from shock, bleeding or infection. Milder physical disability was understood in its own terms - a man might use only one arm, or walk using a crutch, and so be unable to fight, yet could take part in the power games of social life with little or no communication problem. Childhood physical disability has been much increased by poliomyelitis, but apparently only in the past 40 years [13]. Almost a century ago, the British missionary surgeon Theodore Pennell admired Afghan women's skill in suturing their wounded men using ordinary needles and hairs of their own head. He was cooler about the quality of bone-setters' work. Pennell may have seen a disproportionate number of 'failed' cases that had to be sent for Western hospital treatment, while the bone-setters' successes went unnoticed [14].
Compared with blindness and physical disability, people with deafness or mental retardation (learning difficulties) usually pose problems of communication and therefore of understanding 'what is wrong', and of apprehending what might be done to manage the problem. Traditionally, mentally retarded children have been taken to saints' shrines for religious healing. Such practices do not necessarily conflict with modern approaches. Shrine counsellors, as well as some traditional rural healers, are sometimes quite competent 'barefoot psychologists', giving practical advice to clients where they think it beneficial. If 'modern' resource centres take the trouble to acknowledge the practice and potential of such counsellors and healers, and to supply them with relevant information, they may be effective channels. For example, they may still tell families to attach an amulet (tawiz) to the child, but also to engage in a simple developmental program, and to trust in divine mercy [15]. Muslims are enjoined to seek knowledge from every quarter, since all true knowledge comes from Allah. Therefore if Allah has provided knowledge by which families could teach their mentally retarded child, such knowledge cannot be rejected.
Respectful Assistance
When political stability finally returns to Afghanistan and the time comes to blend some modern techniques with the traditional cultural heritage, Afghan men and women of goodwill should be able to find both, ready to hand. It will be good if foreign disability advisors recognise that they are entering a land with a long history of ideas and practices in this field, even if formal and institutional services are lacking. In fact, everyone involved in efforts to assist Afghanistan could usefully reflect on another mordant Afghan proverb, embodying the independent spirit of the people. Many disabled people will find it easy to understand this proverb: "Why do you hate me? I never tried to give you anything."
References
1. P. Coleridge (2000) Disability and Culture. Asia Pacific Disability Rehabilitation Journal, Selected Readings in Community Based Rehabilitation, Series 1, 21-38, on p. 34. More precise and detailed data appears in: M-L. Lambert et al. (1997) Household survey of locomotor disability caused by poliomyelitis and landmines in Afghanistan. British Medical Journal 315: 1424-1425. Full text at: http://bmj.com.cgi/content/full/315/7120/1424?view=full&pmid=9418091
2. IRIN [Integrated Regional Information Networks]. Afghanistan: Community-driven efforts help disabled Afghans. UN Office for the Coordination of Humanitarian Affairs. http://www.reliefweb.int/IRIN/asia/countrystories/afghanistan/20010523a.phtml.
3. UNICEF. State of the World's Children, 2001, pp. 78, 94, New York.
4. W. Maley (1998) Mine action in Afghanistan.
http://www.afghanradio.com/special/maley_oct1998.htm
See also: N. Andersson et al. (1995) Social cost of land mines in four countries: Afghanistan, Bosnia, Cambodia, and Mozambique. British Medical Journal 311: 718-721. Full text at: http://www.bmj.com.cgi/content/full/311/7007/718.
5. Profile: Mr. A.R. Sahak, Afghan Disabled Society.
http://www.oneworld.org/landmines.vienna_updates5.html#profile
6. IRIN. Afghanistan: Closing aid organizations deals blow to blind.
http://cbshealthwatch.medscape.com/cx/viewarticle/404620
7. B. Kristiansson (1990) Report on Rehabilitation Services in Kabul. UNOCA, Peshawar. Ibid. (1991) Report on Takhar Mission, Disabled Afghans Project. Peshawar.
8. R.W. O'Connor (ed) (1980) Managing Health Systems in Developing Areas. Experiences from Afghanistan. Lexington Books, Lexington, Mass.
9. The Hedaya: A Commentary on the Mussulman Laws, transl. C. Hamilton, ed. S.G. Grady, 2nd edn (1963), pp. 526-529 (vol.III, Bk XXXV, ii); 707-708 (vol.IV, Bk LIII). Reprint 1975, Lahore: Premier Book House.
10. Babur-Nama (Memoirs of Babur), transl. A.S. Beveridge (1921) reprint 1989 in 1 vol., pp. 88-89, 106-107, 109, 120-21, 169-170, 258, 261-62, 409, 413; 585, 588, 608, 615, 618-20, 701-702. Delhi: Low Price Publications.
11. L. Dupree (1973/1980) Afghanistan, 73, 116, 118, 335-36. Princeton University Press.
12. S. Thorburn (1876) Bannu or our Afghan Frontier, 280, 398, 411. Reprint 1978, Lahore: Sang-e-Meel.
13. L. Fischer (1968) Afghanistan... A Geo-medical Monograph, 121. Heidelberg: Springer-Verlag Berlin.
14. T.L. Pennell (1909) Among the Wild Tribes of the Afghan Frontier, 40-43. London: Seeley.
15. M. Miles (1997) Afghan children and mental retardation: information, advocacy and prospects. Disability and Rehabilitation, 19: 496-500.
|
