Handicap International Physiotherapy Support in the Afghan Refugee Camps of Baluchistan, Pakistan
By Sudha Raman, M.Sc.(c), Physiotherapist
Afghanistan has had a long history of conflict. Situated in a strategic geographical area, the country has often faced internal strife and has been overrun by foreign invaders with imperial ambitions: Persia and India in the 16th and 17th centuries, and between Britain and Russia in the 1800’s. Since Afghanistan’s Independence in 1919, Russian and US interests were played out on Afghan land, and after the Soviets withdrew in 1989, rival Afghan factions fought a fierce civil war that led to the rise of the Taliban. After Sept 11/01, the US and their allies began a military campaign, and defeated them. This most recent conflict set the conditions for the most recent flood of refugees into Pakistan, the area where Handicap International Belgium (HIB) was working in 2002.
Afghanistan is a ‘Post’-conflict situation the lack of a strong central government leads to warlordism and insecurity. As well, decades of war, drought, ethnic violence and lack of funding combined to create a precarious humanitarian situation for the people of Afghanistan.
Afghan Refugees in Southern Pakistan
HIB was working with people in the refugee camps around city of Quetta in the southern Pakistani state of Baluchistan. Many of the Afghan refugees from the southern province of Kandahar were also of the Pasthun ethnic identity over the southern province of Kandahar.
The UN estimates that there are about 1.5million Afghan refugees in all of Pakistan. The camps in which I was working had about 200 000 people in three main sets of camps. Though the situation in the camps was dire, at least in terms of food, water and adequate shelter, many refugees did not want to return to Afghanistan, citing reasons of insecurity, a lack of employment opportunities, and drought. Population Health Status Afghanistan is one of the poorest and least-developed countries in the world. Access to basic services, such as healthcare and education, is limited or non-existent throughout most of the country. Afghanistan has one of the highest maternal and infant and child mortality rates in the world. The infrastructure has been destroyed by two decades of war, and much of the country is heavily mined. Eighty percent the 28 million people of Afghanistan depend on agriculture or livestock to earn a living. Afghanistan is the world’s largest producer of opium, and poppy cultivation is on the increase. The life expectancy is 43 years, the average income US$150, and literacy is 43%, as low as 4% in women in some areas. The province of Baluchistan bears many similarities Kandahar Province, and importantly shares an ethnic (Pashtun) identity. The refugee camps also housed Baluch, Hazara, and nomadic Kutchi tribes. Disability and Rehabilitation Issues Local surveys indicate that about 3% of the population of Afghanistan is disabled, though it is difficult to get a true value. Some populations at higher risk were nomadic people, soldiers, and those with war injuries. Of course, the Afghan countryside is littered with over ten million landmines and other unexploded shells from the war. The causes of disability are often polio, injuries from landmines and violence, and disease as a result of poverty and poor access to medical care. People with cerebral palsy, amputations and other orthopedic conditions, like back pain, were all common. Many people with disabilities in refugee camps were at a greater disadvantage as they had trouble obtaining their basic rations and relied heavily on their families for assistance. Many disabled people are hidden from view, especially disabled women and children, trapped by their culture and lack of services to the private sphere. Disability is generally seen as a medical problem or one brought about by divine punishment or bad luck. The quest for a cure through medical or religious intervention can be very important for family members. Such attitudes (common in many place in the world) make it difficult for rehabilitation programs, which do not offer a cure, to gain respect. Some disabilities are more ‘acceptable’ than others. Amputees are more easily accepted; in part because their ability to communicate and reproduce is not impaired and because they may be regarded as having made a sacrifice in war. On the other hand, congenital conditions are often regarded as shameful. It is common for parents to claim that their child developed the condition after a bomb attack in order to conceal the congenital nature of the disability.
Rehabilitation and physical therapy in the Quetta and Kandahar area
The physiotherapists (PTs) in the area were those who had a Bachelor’s degree from urban universities (i.e. Karachi, Islamabad). Interestingly, the programs appear to be mostly theoretical, with little clinical learning. In Quetta, in the late 80’s and early 90’s, HI had trained Afghan and Pakistani physiotherapy assistants (PAs) with a 9-month program taught by international staff to fill the need of the refugees both in camps and in the urban Quetta area. These graduates, many of whom had been working at state hospitals or with schools since, formed the main group of rehab professionals in Quetta in 2002. Continuing education is very minimal.
The lack of a training centre in the area and the economic situation has resulted in a shortage of rehabilitation therapists. The refugee population had even worse access to health care than the local population, so HIB was the only organization focused on the needs of people with disabilities in the refugee camp setting.
Personal Experience I was based out of Quetta, Pakistan for 5 months over the end of 2002 and the beginning of 2003. I traveled overland to the program in Kandahar frequently to meet with the rest of the team at the main office in Kandahar city. Handicap International Belgium (HIB) and HI France are the only two operational sections of HI. HIB, the organization that I worked with, has a budget of about 14 million Euro annually. These resources are from international institutions (45 %), national institutions (30%), and fundraising (30%). As one of the lead organizations focused on disability issues, HIB has programs in 60 countries that are under three main pillars 1) Prevention- including mine risk education, landmine clearance action, road safety, disease prevention (i.e. vaccination program support), policy and lobby action (like the international campaign to ban Landmines) 2) Physical Rehabilitation- institutional support and CBR programs, establishing rehabilitation centres, training therapists and technicians, providing equipment, orthoses and prostheses 3) Social Reintegration- vocational training and income generation The France and Belgium sections have Human Resource Departments that manage the various physiotherapists, prosthetists, orthototists, administrators, managers, logisticians and other staff that make up a mission. Usually there are 2-4 international staff members that work with locally hired national staff to manage the programs. Vacancies are listed on their website; usually around a 1-2 year commitment is required. The HIB provided a three week training and orientation period (in Brussels), and covered the cost of flights, visas, accommodation. There is a salary and per diem that is set for each contract. The Kandahar/Quetta Project The three objectives of the HI mission included 1) supporting the Orthotic, prosthetic and mobility aids workshop in Kandahar, 2) supporting the female section of the Rehabilitation Centre in Kandahar and 3) providing support for the most vulnerable people in the Afghan refugee camps in Pakistan. I was responsible mostly for the 3 rd objective. This involved overseeing a group of 5 PAs and 1 PT in their weekly rotations between 9 rehabilitation clinics (actually tents in refugee camps). There was a local operational manager, and I worked with him to settle issues of housing, scheduling, equipment ordering and distribution. I also provided educational updates for the physiotherapy staff through inservices and clinical supervision. Education and treatment of children with disabilities and their families was also one of my objectives. As the project neared conclusion, I liaised with other community organizations to teach the basic principles of seating and mobility aids use. I also advocated for the people we referred to organizations in Quetta, such as a charitable orthopedic hospital for Afghan refugees.
As the camps were spread out, there was a lot of traveling. Security concerns necessitated that we not stay overnight at the camps, and never drive at night. Traveling in certain areas of Baluchistan required the protection of 2 armed guards, accompanying us in another car. My colleague, a Belgian project manager, tried to organize his travels with mine. Successes There were many, given the short time I was there. The first was that HIB had female physiotherapy assistants. This allowed us access to women and children that would generally not be able to be seen by male therapists. Being a woman, I was also able to assess needs that may have been missed by international male staff. In addition to the many therapy sessions, and the walkers, canes, crutches and wheelchairs provided to these very needy people, we were able to make some lasting links with other NGOs to continue with basic disability awareness once our project had finished. A short one-day equipment distribution and assessment was made in an urban Afghan community in Quetta, in conjunction with the World Health Organization office. This was to increase awareness of disability prevention through vaccination and indicate the intentions of the WHO and other organizations that support people with disabilities as well. Permission for a vaccination program was granted following this event. Some Challenges The main hindrances to working in Quetta and the refugee camps were the security concerns, such as the difficulty of travel and hartals (general strikes) that effectively shut down the city. The project was funded on a short (1 year) time frame, in response to the emergency after Sept 11/01. The finite and short-term nature of the project was frustrating as the long-term needs were evident. Conversely, the day-to-day implications of working in a primarily Muslim world as a therapist, such the separation of women and men, Ramadan (the period of fasting) and observation of appropriate dress and behaviour, were relatively easy to accommodate. Conclusions Rehabilitation issues in the context of a short-term post emergency mission are very different from those encountered while working in places where the sustainable development project model is ideal. It was understood, though difficult to realize that education, long term rehabilitation and health issues were second to the primary concerns of food, water, and shelter in the day-to-day struggle for refugees. Afghanistan continues to have poor security conditions and little law and order. As well, unfortunately, the murders of people in the non-governmental organizations have increased the non-governmental organizations’ concerns that the deteriorating security situation in the country will hurt the people who need help most. Until these things improve, people will continue to flee. The Afghan refugees’ solution is multifaceted and requires coordinated efforts to address the underlying causes.
Sources Acknowledged:
Coleridge P. Development, Cultural Values, and Disability: The Example of Afghanistan. Paper presented at conference: ‘Disability Issues: global solutions and the role of community based rehabilitation. Queen’s University, Kingston, Canada, March 5-6, 1998
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