Bringing Hope, Healing to Mideast War Survivors: O&P Plays Its Part
June 2015 Issue
Photograph courtesy of Frederik Buyckx/Handicap International.
Warfare in the Middle East continues to take a staggering toll, unleashing an unprecedented humanitarian crisis. Thousands of civilians have been killed or injured; millions have fled to neighboring countries or safer areas within their own countries. Buildings have been bombed and shelled into rubble and essential parts of the infrastructure, including power plants, water systems, roads, and bridges, have been badly damaged. Many schools have closed. Economies have faltered.
Many medical facilities have been damaged or destroyed. Healthcare resources are being stretched thin or collapsing as physicians and other healthcare professionals flee and medical supply inventories shrink. Humanitarian aid workers have been attacked and killed. However, after the immediate medical triage from such conflicts is addressed and initial treatment has been provided, rehabilitation needs remain-for which O&P plays its part.
O&P in Humanitarian Healthcare
National and international humanitarian organizations from small and local to worldwide are stepping into the breach. Healthcare needs encompass a wide spectrum. For instance, there are patients who require emergency care due to war injuries, as well as people who have preexisting disabilities, chronic illnesses, and other illnesses and injuries, but can no longer access their usual healthcare and rehabilitation facilities, including those that provide prosthetics, orthotics, and physical therapy. Handicap International (HI) estimates that in Syria alone, approximately 1 million people have been injured; about 80,000 of them will require an orthosis or prosthesis. Some physical rehabilitation programs, including that of the International Committee of the Red Cross (ICRC), focus not only on immediate need but also on building a country's capacity to supply P&O care and related physical therapy, with an emphasis on the quality of services and devices.
In cooperation with the International Society for Prosthetics and Orthotics (ISPO), the ICRC also emphasizes and supports the development of P&O schools and other training programs, especially in areas of need.
Focus on Syria
Syria's refugee crisis surpassed 3 million people in August 2014, "amid reports of horrifying conditions inside the country," according to a statement released by the Office of the United Nations High Commissioner for Refugees (UNHCR). "These include cities where populations are surrounded, people are going hungry, and civilians are being indiscriminately killed. Almost half [of] the Syrian population has been forced to abandon their homes and flee for their lives. One in every eight Syrians has fled across the border, with a further 6.5 million displaced within Syria." Later figures from the U.S. Agency for International Development (USAID) place the refugee population at almost 4 million, along with 7.6 million internally displaced persons (IDPs).
Drawing on reports by UNHCR and other aid agencies, the statement adds, "Increasing numbers of families are arriving in a shocking state, exhausted, scared, and with their savings depleted. Most have been on the run for a year or more, fleeing from village to village before taking the final decision to leave." The journey is becoming tougher with many people forced to pay bribes at armed checkpoints along the borders and with smugglers demanding hefty sums to take them to safety.
Most refugees remain in neighboring countries, with the highest number in Lebanon (1.14 million), Turkey (815,000), and Jordan (608,000), according to the statement. "This has led to an enormous strain on their economies, infrastructure, and resources. More than four in five refugees are struggling to make a living in urban areas, with 38 percent living in sub-standard shelter...."
Aid Organizations Work Hard to Help
Although a variety of international and within-country agencies are working hard to help, this article focuses on just three-HI, the ICRC, and Médecins Sans Frontières (Doctors Without Borders).
Bringing together volunteer and employed workers from many faiths and ethnicities, these agencies help, in an impartial manner, to provide food, shelter, equipment, and supplies, along with emergency and longer-term healthcare to those in need. They provide mental health services and counseling to help people deal with the stress brought on by living in war zones or in the aftermath of natural disasters. They partner with other organizations and seek to assist in-country service agencies and medical and other healthcare facilities with training, equipment, supplies, and personnel. The organizations work to develop sustainable, ongoing programs within the affected countries for a better future as well as for the practical benefit of having aid partners within affected countries to carry on in the event of border closings, attacks on foreign aid workers, and expulsion of expatriates.
HI is a nonprofit humanitarian organization that provides aid to people with disabilities and is one of the six founding members of the International Campaign to Ban Landmines (ICBL). The ICBL and landmine activist Jody Williams were co-winners of the 1997 Nobel Peace Prize. The organization's work directly impacts more than 2 million people in 59 countries, according to its website, www.handicap-international.us. Along with other aid, HI responds to the emergency healthcare needs of individuals who are injured, disabled, elderly, or isolated, including IDPs and refugees.
HI's emergency teams have been working in Lebanon and Jordan since the spring of 2012, extending their operations to Syria in 2013, and to Iraq in 2014; about 500 HI professionals are working with the most vulnerable people in these countries.
More than 190 staff work in the field on a daily basis combing the camps and communities, particularly in urban areas, since the majority of refugees live within those communities, to identify individuals-particularly those with disabilities-who lack essential needs including housing, healthcare, and food, and to assist them in accessing services and basic infrastructures. Healthcare includes superficial wound treatments, physical rehabilitation sessions, supplying and fitting orthoses and prostheses, and donating mobility aids and equipment such as wheelchairs, crutches, and pressure-relieving mattresses. HI refers people it is unable to help to other organizations and continues to follow up on their situations.
Prosthetic and Orthotic Care
"For refugees who are vulnerable people, including unaccompanied children, the elderly, and those with chronic conditions, the first step after assessing their needs is to see what resources for care are in the community. For instance, if they need prosthetic care, we refer them to a prosthetic provider," explains Eric Weerts, HI technical referent, Emergency and Rehabilitation.
"From 2012 to 2014, we relied more on patients [in Syria] being able to obtain prosthetic fittings in Jordan and Lebanon," Weerts continues. "It was the right solution and the most cost-effective since people could easily cross the border and obtain a prosthetic fitting." However, as border closures and security concerns increased, "we rely more on Syrian professionals that we train in prosthetic production, who then return to Syria with the right equipment and training capacity to train staff and also scout for locations to set up prosthetic units."
HI also uses technology that takes advantage of mobile units. "However, for the moment, our approach is shifting by intending to support existing workshops that were already functioning before the conflict, but now are having problems with lack of supplies and staff. We supply them and give them updates on the technical fitting so they can continue their activities as before." Weerts adds, "We also select field hospitals close to prosthetic production in border countries so that persons with amputation can be more quickly referred for fitting once conditions allow it."
Most of the injuries seen are open, closed, and complex fractures, Weerts says. "Depending on available orthopedic care, we close the wound and work with progressive casting." The team makes an early assessment of needs and provides crutches and wheelchairs to enable patients to become mobile as quickly as possible.
The team also looks at the environment the patient will be functioning in after discharge. Using a screening system, they consider the injury itself and the level of care the patient will need to be as independent as possible. "We ascertain if they will have someone to take care of them during the recovery process," Weerts adds. "And a patient with a fracture with nerve damage will need a follow-up and likely lifelong counseling and adjustment." The physical rehabilitation team takes a holistic view of patients, training family caregivers, and providing counseling to patients and families about what to expect in terms of psychological and life changes the patients will experience. He explains that prosthetic technicians, physical therapists, and health workers are always accompanied by a social worker who usually has either a background in social work or life experience as a family member of someone with a disability.
The association also provides a distance learning program about how to treat war injuries to prevent the onset of permanent disabilities.
International Committee of the Red Cross
Established in 1863, the ICRC was at the origin of the Red Cross and Red Crescent Movement. The ICRC, the International Federation of Red Cross and Red Crescent Societies (IFRC), and the National Societies together constitute the International Red Cross and Red Crescent Movement, which closely cooperate to provide impartial neutral humanitarian aid in about 190 countries. In Islamic-majority countries, the National Societies operate under the Red Crescent Symbol, including Syria, Iraq, Yemen, Jordan, and Palestine, among others. The ICRC has won the Nobel Peace Prize three times-in 1917, 1944, and jointly in 1963 with the League of Red Cross Societies, now known as the IFRC.
"The ICRC's Physical Rehabilitation Programme has been active for many years," comments Program Head Claude Tardif, CPO. "We have built up a strong rehabilitation program. Currently we are supporting 125 projects in 32 countries, including Iraq, Gaza, Yemen, Syria, and Lebanon in the Middle East."
ICRC projects are designed and implemented to strengthen the overall physical rehabilitation services in a given country, explains the Physical Rehabilitation Programme 2013 Annual Report (the most recent available). The ICRC supports local partners such as governments, nongovernmental organizations (NGOs) including national Red Cross/Red Crescent societies, and private entrepreneurs to provide services. However, if there is no suitable partner at the outset of the project or a center is set up to treat patients from a neighboring country, the ICRC operates alone. To promote the continued functioning of centers, the ICRC trains and mentors local professionals in technical and managerial skills. The organization has developed several tools to support center managers including stock management, patient management, and treatment protocols. More emphasis is being given to the training component in ICRC-assisted centers, since quality, availability of services, and sustainability depend largely on a continuing supply of trained professionals.
In Syria, the ICRC is supporting provision of appropriate services in Damascus and in Aleppo. In Damascus, the ICRC supports the effort of the Syrian Red Crescent Society, one of the main service providers in the country. "They used to have one center near the airport, but can't continue using it due to security concerns," Tardif says. "Services have been transferred to a small center in Damascus where they are working now." He adds, "We hope to have more places where people can access services." Another center is planned. "We should start to support more centers this year; with the present conditions, it's not easy for people to travel from one place to another."
A delegation from the ICRC met with Mohammad Wahid Aqqad, the governor of Aleppo, to discuss steps taken by the ICRC local office to open a prosthetics center there, according to a Syrian Arab News Agency (SANA) report in September 2014. The governor assured the delegation of the governorate's readiness to provide support in equipping and launching the service as soon as possible. Gandhi al-Zain, assistant director of the ICRC's Aleppo office, noted that the center will be staffed by Syrians after training.
The ICRC also supports 12 prosthetic centers in Iraq, including one in ISIS-controlled Mosul, two in Baghdad, and the Baghdad Prosthetic/Orthotic School.
Médecins Sans Frontières (Doctors Without Borders)
Médecins Sans Frontières (MSF) provides emergency medical care in about 70 countries when catastrophic events, such as armed conflicts, epidemics, malnutrition, or natural disasters overwhelm local health systems, according to its website (www.msf.org). Services range from vaccination campaigns to complex surgeries, and include maternal and pediatric care and fighting neglected diseases, among others. The organization advocates for affordable, high-quality medicines and assists people confronting discrimination or populations that are excluded from accessing healthcare.
Middle East Activities
One of MSF's projects in the Middle East is the Emergency Surgical Programme inside the Al Ramtha Government Hospital, Jordan, where MSF works closely with Jordan's Ministry of Health. With more than 140 national and international staff working for the project, MSF runs two operating rooms, two in-patient and recovery rooms, and two wards.
As the project grew, MSF opened a post-operative care facility in the Al Za'atari refugee camp in March 2014. The 40-bed facility treats patients with war-related wounds who have been transferred from Al Ramtha and other hospitals in Jordan.
MSF operates six medical facilities inside Syria and directly supports more than 100 clinics, health posts, and field hospitals. MSF is also working with Syrian patients who have fled to Jordan, Lebanon, and Iraq.
MSF surgeons perform amputation and limb-salvage surgeries. Although MSF doesn't focus on rehabilitation care, an MSF March 2015 report on Aleppo notes, "For the injured, life becomes even more difficult, particularly if they have lost a limb." Wheelchairs are almost impossible to obtain and hard to move through damaged neighborhoods and ruined houses. "Prosthetic limbs and rehabilitative care are likewise in very short supply." Besides adapting to a less mobile reality, people with amputations are unable to run for cover at the sound of approaching planes and helicopters. These conditions underscore the need for rehabilitative and O&P care.
A complex series of wars, lesser conflicts, and events have followed Israel's Declaration of Independence in 1948. The former mandate of Palestine was partitioned between Israel, Transjordan, and Egypt, explains a BBC overview of the history of Israeli-Palestinian conflicts. Hundreds of thousands of Palestinians fled or were forced out during this early conflict.
During the Six-Day War in 1967 Israel captured the West Bank, Gaza, and East Jerusalem from the Arab coalition. Israel withdrew troops and settlers from the Gaza Strip in 2005 but still controls the airspace, seafront, and all but one crossing.
Although struggling for self-determination, Palestinians have achieved little control over their own affairs, notes the BBC overview. "The economy is fragmented and subject to Israeli restrictions. Much of the population is dependent on food aid."
Movement and access restrictions continue in the occupied territory, undermining Palestinians' livelihoods and impeding their access to basic services, according to the UN Office for the Coordination of Humanitarian Affairs (OCHA).
These restrictions have also impeded healthcare, since many Palestinians go to Israel for health conditions for which care is not available in Palestine. "We have about 1,000 patients a year from Gaza, but Palestinian authorities are only allowing persons with the most severe need in oncology, pediatrics, and rehabilitation to come," says orthopedic surgeon Itzhak Siev-Ner, MD, director of the Orthopedic Rehabilitation Department of the Chaim Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel.
Palestinian access to medical care from the West Bank is easier, Siev-Ner explains, because Hamas, which controls Gaza, is more restrictive.
The majority of pediatric patients receiving care from Save a Heart, an Israeli international nonprofit organization based near Tel Aviv, are from Gaza, Siev-Ner adds. Its mission is to improve the quality of pediatric cardiac care for children from developing countries who suffer from heart disease and to create centers of competence in these countries.
Two ISPO-accredited O&P schools in the Middle East are the Pakistan Institute of Prosthetic and Orthotic Sciences, Hayat Abad, and the Afghan School of Prosthetics and Orthotics, managed by the ICRC, in Kabul.
A blended distance-learning O&P program is offered by the nonprofit organization Human Study e.V. (HS) (www.human-study.org); it combines online academic instruction with on-site, hands-on symposium workshops. ISPO-accredited since 2010, the program is open to new O&P students and practicing professionals.
The HS Category II Single Discipline Program in Egypt and Palestine was launched in February in cooperation with Egypt, ICRC, and other organizations. Currently there are 12 Egyptian and two Palestinian students. The HS Category II Single Discipline Program in Syria and Turkey also began in February in cooperation with the National Syrian Project for Prosthetic Limbs (NSPPL) and Ankara University, Turkey, among others. Currently there are 15 Syrian and four Turkish students.
Bright Spots in a Dark Picture
Dry facts and statistics don't reveal the scope of human hope and suffering. But seeing the smile of a Syrian girl with bilateral transtibial amputations as she takes her first steps in her new prosthetic legs, or a man with a transradial amputation beaming as he tries out his new prosthetic arm paints a picture of how humanitarian care can impact one person's life.
Miki Fairley is a freelance writer based in southwest Colorado. She can be contacted via e-mail at .