Physical Rehabilitation & Humanitarian Emergencies:
Perspectives from Ghana
Yetsa A. Tuakli-Wosornu, M.D., M.P.H.
Member, I.S.P.R.M. Disaster Relief Sub-Committee
Resident Physician, Department of Physical Medicine and Rehabilitation
Sinai Hospital of Baltimore, USA
November 2012


Principles of humanitarian emergencies

Rehabilitation medicine perspective

Conflict in Sub-Saharan Africa

Conflict in Ghana (and our neighbors)

Available rehabilitation resources

Conclusions

Worldwide


Natural disasters
Man-made conflict/occupational catastrophe
Africa




Political instability
Chronic simmering conflict
Human trafficking and child soldier recruitment practices
Deep poverty


Strike suddenly
Unfold gradually


Increase risk of resource shortage (arable land, food)
Disproportionately impact vulnerable groups
USAID
United Nations Office for the Coordination of Humanitarian Emergencies
World Vision Africa

Numerous players often provide collaborative solutions
Humanitarian
Organizations
Non-Governmental
Organizations
Military
Organizations
Development
Organizations
Local Physical
Resources
Local Human
Resources
Image: Conflicts in Africa 2000-09, P.D. Williams, War and Conflict in Africa (Williams, 2011), p.3

Principles and goals of rehabilitation are shared among aid groups
Humanitarian
Organizations
Principles:

Humanity



Impartiality
Neutrality
Independence
NGO’s
Development
Organizations
REHABILITATION
Principles:

Humanity



Impartiality
+/- Neutrality
+/- Independence
Goals:

Alleviate suffering
(short term)

Re-establish choice
Goals:

Alleviate suffering
(medium to long term)

Sustainability

Considerations for effective rehabilitation medicine during crises

Experience

Crisis zone

West Africa (resource-limited, a priori)

Implementation of appropriate short and medium/long term care plans (standards of care may need to be adjusted in light of restricted sanitation and follow up availability)

Equipment

Durable medical equipment

Medications and means of sterilization

Portable and accessible shelter and lavatories

Local infrastructure provides the backbone of rehabilitation in a crisis
P ASSABLE ROADS
F UNCTIONAL VEHICLES
H OSPITALS
S ANITATION , DME, SHELTER
T RAINED PERSONNEL
T
ELECOMMUNICATION

Sub-Saharan Africa suffers extreme and unique poverty
Nation-states characterized by average life expectancy (2012)
Poverty
Severe
Complex
Multi-generational
Disabled World 2012 (www.disabled-world.com)

West African sub-region plagued by food shortages, famine (and conflict)
Oxfam UK (www.oxfam.org.uk)

• Equitorial West Africa, immediately bordered by
Cote d’Ivoire, Burkina Faso,
Togo and Gulf of Guinea
• Part of the 17 country
West African sub-region
•
Ethnic heterogeneity (10 municipal regions, 170 districts) http://maps.grida.no/go/graphic/ghana_topographic_map

Raleigh, C (2011) The search for safety: the effects of conflicts, poverty and ecological influences on migration in the developing world, Glob Env Change

Risk situations encircle but do not directly afflict Ghana
① Neighbors
West African nation-states historically stained by corruption, bad governance and conflict
② Resources
Newly discovered off-shore oil introduces the theoretical threat of the “Dutch Disease” and/or the
“Resource Curse”

Ghana enjoys a stable socio-political climate but it’s neighbors do not
Mail:
2/2012 Tuareg rebels attack civilians rendering border volatile; supplies in Ghana
Liberia:
Two “successive” civil wars to 2003; displaced many; refugee status to be removed
Nigeria:
Recurrent political and resourcerelated conflict, small and large
Cote d’Ivoire:
2010 political impasse (Gbagbo v. Outtara) led to post-electoral v
United Nations Office for the Coordination of Humanitarian Emergencies
World Vision Africa

Cote d’Ivoire exemplifies principle of humanitarian struggle in Africa

Ethnic heterogeneity no longer viewed a the critical determinant for degeneration into a failed state

The Dutch Disease and the Resource Curse

Perceived ethnic discrimination (non-symmetric redistribution of state investments)

Partisan politics (asymmetric representation of ethnic heterogeneity in government)

Deep poverty (limited economic, emotional, reserve)
West African Nation-States remain at risk
Ištok R and Koziak T (2010), Ivory Coast – From stability to collapse: failed states in time of globalisation In Beyond Globalisation: Exploring the
Limits of Globalisation in the Regional Context (conference proceedings), 81-87. University of Ostrava Czech Republic

Resource-related turmoil has affected
West African nations

Ethnic heterogeneity no longer viewed a the critical determinant for degeneration into a failed state

The Dutch Disease and the Resource Curse

Perceived ethnic discrimination (non-symmetric

Partisan politics (asymmetric representation of ethnic heterogeneity in government)

Deep poverty (limited economic, emotional, reserve) track record of amicable foreign relations
Neubauer C (2010) “Ghana discovery sparks fight over oil” in The Washington Times, http://www.washingtontimes.com/news/2010/mar/26
The Economist (1977)

If we did face an humanitarian emergency, how would we fare?
Could we accommodate
PWD?

Capacity

Medical

Government (including military)

Foreign governments/aid and international organizations

Capacity for emergency-related care limited by space and staff

Acute (short-term) medical management

Komfo Anokye Teaching Hospital (Kumasi)
 1000 beds, 133 for general trauma, separate Burns I.C.U., recently expanded

Korle Bu Teaching Hospital (Accra)
 1500 beds, 3 ortho and 2 neurosurgeons

Post-acute (long-term) management

20-30 PTs, 1 retired OT, 1 SLP, No PMR

Only 6 PMR in all of sub-Saharan Africa
Christian A et al. (2011) Rehabilitation needs of persons discharged from an African trauma center, Pan Afr Med J 10(32)
Haig AJ et al. (2009) The practice of physical medicine and rehabilitation in sub-Saharan Africa and Antarctica, International Rehab Forum
Tinney MJ et al. (2007) Medical rehabilitation in Ghana Dis Reh 29(11-12):921

Local infrastructure provides the backbone of rehabilitation in a crisis
P ASSABLE ROADS
F UNCTIONAL VEHICLES
H OSPITALS
S ANITATION , DME, SHELTER
T ELECOMMUNICATION
T
RAINED PERSONNEL

Tro-tros are crowded and inaccessible

Risk situations encircle but do not directly afflict Ghana
① Neighbors
West African nation-states historically stained by corruption, bad governance and conflict
② Resources
Newly discovered off-shore oil introduces the theoretical threat of the “Dutch Disease” and/or the
“Resource Curse”

Recent man-made disaster gently tested medical capacities






2007 – 2008
Four separate petrol-related fire disasters occurred in
Ghana’s middle belt (Ashanti region) as a result of roadside accidents
212 injured
17% (n=37) died immediately
83% (n=175) reported to KATH trauma unit; 26%
(n=46) admitted with an average burned body surface area 63%
PWD involved or created were not reported
Agbenorku P (2010) Burn disasters in the middle belt of Ghana from 2007 to 2008 and their consequences, Burns 36(8):1309

2011 natural disaster engaged USAID in an untraditional way







10/26/2011 Heavy rainfall caused flooding in Accra,
Eastern region and Volta region
43,000 people affected
14 deaths
Buildings, livelihood resources, >400 acres of farmland
NADMO conducted search-and-rescue operations and deployed rapid assessment teams to evaluate damage and distribute emergency relief supplies
Inadequacy of emergency relief commodities and food prompted USAID office of U.S. Foreign Disaster Assistance to provide $50,000 for emergency relief supplies
PWD involved or created not reported
United Nations
USAID
Ghana National Disaster Management Organization

①
Planning
Ghana is encircled by risk situations and humanitarian emergencies – improved planning for existing and new PWD’s
(including refugees) is needed including accessibility tools
②
Building
Build on pre-existing facilitators for care including sophisticated trauma units and the presence of active international organizations; these can be expanded to include specific contingency plans (both built environment and staff training) for vulnerable groups

END

The “Resource Curse”
(the Dutch disease)
Countries who depend on natural resources for export:
Large inflows of foreign currency reduce the competitiveness of that country’s exports.
Large inflows of foreign currency reduce accountability and encourage corruption.
The natural resource boom crowds out other important sectors of the economy.

Disability (and poverty) is a biopsychosocial construct
Disability
“…impairments, activity limitations & participation restrictions. It denotes the negative aspects of the interaction between an individual (with a health condition) &
[their] contextual factors…”
Poverty
Non-monetary factors (education, health, living conditions) and monetary factors
(income versus consumption expenditures, individual & household assets)
Health expenditures
Low income
Cultural factors
(stigma)
Environmental factors
Full participation in society
Poor sanitation
Chronic, poor health
Personal factors Under education
International Classification of Function, Disability and Health, W.H.O. 2001 de Janvry AD and Kanbur R eds. (2006) Poverty, Inequality and Development: Essays in Honor of Erik Thorbecke, Vol 1 (Springer)

Removing barriers enables full participation in society
Disability
“…impairments, activity limitations & participation restrictions. It denotes the negative aspects of the interaction between an individual (with a health condition) &
[their] contextual factors…”
Poverty
Non-monetary factors (education, health, living conditions) and monetary factors
(income versus consumption expenditures, individual & household assets)
Health expenditures
Low income
Cultural factors
(stigma)
Environmental factors
Full participation in society
Poor sanitation
Chronic, poor health
Personal factors Under education
International Classification of Function, Disability and Health, W.H.O. 2001 de Janvry AD and Kanbur R eds. (2006) Poverty, Inequality and Development: Essays in Honor of Erik Thorbecke, Vol 1 (Springer)

Relationship between disability and poverty remains tangled
Disability
Cultural factors
(stigma)
Environmental factors
Personal factors
Poverty
Health expenditures
Low income
Poor sanitation
Chronic, poor health
Under education
International Classification of Function, Disability and Health, W.H.O. 2001 de Janvry AD and Kanbur R eds. (2006) Poverty, Inequality and Development: Essays in Honor of Erik Thorbecke, Vol 1 (Springer)

Risk situations and emergencies further stress this reserve-limited system
Disability
Cultural factors
(stigma)
Environmental factors
Personal factors
Poverty
Health expenditures
Low income
Poor sanitation
Chronic, poor health
Under education
International Classification of Function, Disability and Health, W.H.O. 2001 de Janvry AD and Kanbur R eds. (2006) Poverty, Inequality and Development: Essays in Honor of Erik Thorbecke, Vol 1 (Springer)

Foreign presence includes eight subregion “Super Powers”
China, France, UK, USA, Germany, Japan, EU, UN
 Interests – economic; energy resources e.g. uranium and oil
 Military (US, France, UK)
 Platforms of concern cited – poverty, disease, crime, terrorism, state collapse, state failure
 USAID has a large presence in Ghana and focuses on emergencies
Tinney MJ et al. (2007) Medical rehabilitation in Ghana Dis Reh 29(11-12):921

Children possess both economic and social value in Africa
Social Value Economic Value
 Present in all families in the
West and West African sub-region
 Inversely proportional to a family’s socio-economic status, esp. in W. Africa
 Outweighs economic value in wealthy families
 Outweighs social value in poor families
Upsurge in child trafficking

Culture of child trafficking includes
Ghana
Industries Rich in
Child Labor
① Agricultural
② Domestic
③ Fishing
Ghana’s Top industry