REHABILITATION MATTERS

145 casualties from mines and explosive remnants of war were reported in Colombia in 2022. Colombia is among the five countries where new use of antipersonnel mines by non-state armed groups has been reported in 2022. Indeed, the number of incidents of mines attributed to non-state armed groups has increased by 30% since 2021. (Landmine Monitor 2023)

Andrés attended hospital physiotherapy and speech therapy sessions, and he started the process of being fitted for his first prosthesis. The second amputation hit him very hard psychologically, and he felt angry, sad, and disillusioned. However, he did not receive psychological counselling at that time.

Victim assistance (VA) has always been among the less well-funded pillars of Humanitarian Mine Action (5% of the total global mine action budget in 2021 and 2022). In 2021, dedicated international financial support from the global mine action budget for VA reached its lowest level recorded since 2016, despite the growing needs. (Landmines Monitors 2022 and 2023).

Once discharged from hospital, Andrés moved to Pasto, the capital city of Nariño Department, where he could have better access to services and start a new life. With continuous occupational therapy and physiotherapy interventions, Andrés became more hopeful, but still uncertain about what he would do from then on. Andrés was able to rely on the psychosocial, livelihood, and legal support provided by the “Pastoral Social”, a diocesan organisation in Pasto, and Humanity & Inclusion.

“Recovery was a bitter process, because the system is precarious and there is little state support and aid for the victims.”

While overcoming the physical and emotional pain, Andrés did everything he could to find the best prosthesis that would meet his needs and match his preferences. This did not prove to be an easy journey, in a system that still considers good-quality and high-tech assistive technology (like prostheses) to be luxury products. His first basic prosthesis, provided by the public system. did not enable him to have full mobility and independence, for example, he could not walk on bumpy paths or climb stairs, and he felt quite uncomfortable and sore. He knew that this prosthesis was not right for him, so he started looking for a better prosthesis that would meet his needs. Once Andrés had a clear idea of what he needed, he went to a traumatologist to obtain a prescription. Andrés found several administrative hurdles in his way, with a lot of back-and-forth from one medical service to the other. In addition, the medical professionals often questioned his request for a better prosthesis, which was seen as something “nice to have”, not as a necessity.

Andrés finally got a high-tech prosthesis six years after the accident. Thanks to his determination, he managed to get his new prosthesis fully funded by a public welfare scheme. Since then, Andrés has changed his prosthesis twice to ensure that it is adapted to him and properly maintained. 
Receiving and adapting the prosthesis requires multiple trips to the capital city, Bogotá, and staying there over long periods. The cost of travel and staying in the capital was a significant out-of-pocket expense for Andrés, who never gave up and undertook different work projects to top up his welfare benefit entitlement.

The cost of a prosthesis can vary significantly, depending on the quality, manufacturer, and level of technology. A high-quality limb prosthesis can cost around 40,000 USD in Colombia, while the average monthly salary is around 500 USD

Since the affordability of assistive technology also depends on travel costs and loss of income for users and their families when accessing the services, adequate measures to reduce such indirect costs should be considered (WHO and UNICEF “Global Report on Assistive Technology” 2022).

Although Andrés could not fulfil his dream of studying in the Colombian Air Force, and he was forced to temporarily stop his education, he managed to complete his civil engineering degree and graduated in 2022. He is currently looking for job opportunities in this field. 

Andrés is an active person in his personal life and in the community. With his good-quality prosthesis, he does sport and has joined a Paralympic group. Furthermore, Andrés has become involved in the peer-to-peer support strategy run by the “Pastoral Social”.  
Andrés is certainly living proof that moving on is possible. Through visits, active listening, and sharing, he supports other people who are going through the same experience as he had years ago as a victim of explosive ordnance. 

The 2019 Oslo Action Plan sets out 50 concrete actions that States Parties to the Anti-Personnel Mine Ban Convention should take by 2025 in order to make tangible progress towards ending the suffering caused by anti-personnel mines. One of these actions explicitly refers to comprehensive rehabilitation services and psychological and psychosocial support services, including via peer-to-peer support programmes.

By the end of 2022, there were 4.8 million people registered as living in internal displacement in Colombia, as a result of conflict and violence (Internal Displacement Monitoring Centre, 2023).

Gloria was living with her family in a rural district in the Nariño Department. Paramilitary forces had taken control of the area during fierce fighting over territory. The eight family members escaped immediately, including Gloria’s son, Sebastian, who has Down’s Syndrome and several health conditions. They headed for Pasto, where some relatives were living. “Our relatives’ flat was too small to house all of us, so we had to sleep on the floor, and there was not enough food,” says Gloria. Sebastian, who was 17 at the time, found it hard to adapt, and he still felt afraid.

In 2023, 23,000 persons with disabilities were registered in Pasto. Of those, 3,000 are victims of the conflict(. Secretaría de Salud, Alcaldía de Pasto).

However, things got better with time. A few months later, they were granted “Internally Displaced People” status by the public authorities, meaning that they gained access to humanitarian assistance, and Gloria and her son obtained the right to live in a flat provided by social services.

Fleeing their home was a traumatic experience, but Gloria also sees a positive side. In Pasto, a bigger city, her son Sebastian has received the health, rehabilitation and social care that he needs. This was not possible in their small village, which was badly affected by the armed conflict.  

Globally, rehabilitation services are often concentrated in urban areas, making for access issues for people living in remote and/or rural areas. These challenges are exacerbated in contexts marked by violence and instability, where travelling to the place where the services are provided becomes even more complex, and also because of the mine threat. Indeed, Nariño is one of 16 Colombian departments contaminated by landmines (Landmine Monitor 2022).

Since settling down in their new city, Sebastian has received regular occupational therapy and speech therapy sessions. These rehabilitation interventions have been very helpful for developing coordination, crafting, and communication skills. In addition, Sebastian is part of the music group run by the “Fundación Batuta” and enjoys performing live with the other members of the group. 
While Gloria is generally satisfied with the support her son has received, it has been difficult for him to access physiotherapy, which Sebastian needs for his balance issues, due to the long waiting list and the limited number of available physio appointments.

The vast majority of rehabilitation services, including physiotherapy, are delivered at the secondary and tertiary level of care (hospitals and specialised centres), while they are almost absent from primary healthcare. The provision of rehabilitation in primary healthcare, as close as possible to where people live, has the potential to increase access.

In addition, the social welfare scheme covers the costs of medical and rehabilitation care, but a few costly products are excluded from this coverage, like skin products and incontinence pants.
Social, health and rehabilitation services were significantly disrupted during the COVID-19 pandemic. “Despite attending some online health appointments and therapy sessions, Sebastian went backwards, because in-person therapies are much more effective.” It was a very difficult time for Gloria and Sebastian, who were isolated and lived in fear of the disease, as Sebastian’s health conditions meant that he was vulnerable to COVID.  

During the COVID-19 pandemic, many persons with disabilities and their families have been disproportionately affected by social movement restrictions, physical distancing requirements and prioritization of certain health services–all of which have affected their access to essential services which are critical to maintaining health and functioning (WHO, Global report on health equity for persons with disabilities, 2022).

Hmoud currently lives in the city of Intesar in Nineveh Province. He and his family had to flee their hometown, Sinjar, when ISIS arrived. In his new town, he is renting a small house where he, his wife, their two sons, with their wives and their children, live together. He is unable to stand and walk and uses a wheelchair to move around the house due to his war injuries. He needs support with personal care and performing  routine activities. Hmoud remembers exactly how he was injured: “I didn’t buckle my combat helmet, I liked to wear it in a stylish fashion. Therefore, as the mortar struck, my helmet flew away and I was hit. I was in Basra, at the border of Iraq and Iran, and I was immediately brought to Baghdad for open brain surgery.”

The injury has deeply impacted Hmoud’s life. His motivation, hope, and strength gave way to feelings of isolation and disappointment. He cannot live independently, is unable to attend social gatherings, and had to give up his hobby of buying and selling vehicles, for which he travelled all over Iraq. 

In the interviews conducted by the International Organization for Migration (IOM) with 81 representatives of Organizations of Persons with Disabilities in Iraq, respondents shared that the abilities of persons with disabilities and the contribution they can make to communities are not recognized. When persons with disabilities are not (seen to be) active members of their communities, they become isolated and marginalized.
(International Organization for Migration (IOM), "Persons with disabilities and their representative organizations in Iraq: Barriers, challenges, and priorities", 2021).

“I feel ashamed asking others to help me move around. I started to feel this sense of exclusion the moment I sat in the wheelchair.”

He would like to attend ceremonies and family gatherings, but moving around is a real challenge because buildings, public places, roads, and even service infrastructure are not accessible. Hmoud keeps himself busy by browsing the internet and making friends online. 

Hmoud did not have to wait a long time to receive his well-adapted wheelchair. However, the rehabilitation he received was not sufficient. Shortly after the injury, he had roughly one month of physiotherapy. “After only one month of physiotherapy, I was able to walk 8-10m on crutches, and I was gradually performing tasks at home.” However, this significant progress was lost when there was a long interruption to his rehabilitation plan.

In Federal Iraq, each governorate provides rehabilitation services in their main specialised rehabilitation centre. A small number of physiotherapy departments also exist in general hospitals, but none are available at a primary or community health care level.
(Humanity & Inclusion Iraq, "Health Technical Strategy 2023-25")

Hmoud encountered numerous  obstacles: the absence of services in the area where he lives,  the worsening financial situation in his household with only the two sons bringing in a modest income, the lack of government support, and the limited support from humanitarian organisations. Furthermore, Hmoud did not feel comfortable doing some of the exercises with a female physiotherapist. 

It is pivotal not only to increase numbers in the rehabilitation workforce, in terms of training and posts created, but also to ensure gender diversity in the workforce. Indeed, worldwide, services are often delivered without accounting for diverse gender needs or requirements.
(ReLAB-HS, "Rehabilitation through a gender lens", 2021).

Although in recent years Hmoud benefited from rehabilitation delivered by the NGO Humanity & Inclusion, it was not enough to restore his mobility after so many years. 

Hmoud hopes to receive rehabilitation and improve his mobility. The lack of public and humanitarian support is challenging in the area where Hmoud lives; an area contaminated by explosive ordnance, and where many people still have to contend with the consequences of conflict on a daily basis.  

In 2022, protracted internal displacements, explosive ordnance threats and limited availability of basic services and livelihoods left 2.5 million people still in need of humanitarian assistance in Iraq.
Despite extensive efforts by humanitarian partners to clear contaminated areas, approximately 3,016km² of land remains contaminated, and the full extent of contamination is undefined.
(OCHA. Humanitarian Needs Overview Iraq, 2022.) 

Iraq is one of the most heavily Explosive Ordnance contaminated countries in the world with an estimation of 3,225km² of land being contaminated. In 2021 it was estimated that 8.5 million people in the country were at risk due to the contamination.
(Humanity & Inclusion report, 2021, No safe recovery: The impact of Explosive Ordnance contamination on affected populations in Iraq)

At such a young age, Shaha has already undergone five jaw and three eye surgeries. She now has prosthetic eye lenses and wears glasses. Shaha had difficulty in moving her right hand, but with the physiotherapy that she has received from Humanity & Inclusion’s professionals she is now able to move her hand and fingers. As Shaha gets older, she will need additional physiotherapy sessions to maintain good mobility in her hand. 

Shaha’s mother is grateful for the support provided by neighbours, friends and Humanity & Inclusion’s staff. “With the help of kind people, we were able to pay for Shaha’s eye surgeries, and the support of Humanity & Inclusion not only helped Shaha but also encouraged me to stay strong.”  The family could not have otherwise afforded these health and rehabilitation costs, considering that the only source of income was her sister’s sewing work.

The horrors of the war not only caused physical but also psychological suffering. 

"Shaha’s psychologist said that her life stopped at the moment of the explosion,” says Shaha’s mother. 

After the explosion, Shaha couldn’t speak, was constantly having nightmares, and developed eating disorders. The psychotherapy sessions in which she took part for over a year-and-a-half had a very positive impact on her wellbeing and ability to communicate. Shaha is happy to go to school, although she does say that  “girls in school bully me because I wear glasses and I have burns.”

Mental health concerns increase in countries affected by explosive ordnance as experiencing distressing and traumatic events caused by long-term violence can result in debilitating levels of reduced self-esteem, permanent and lifelong disability, depression, feelings of insecurity, social withdrawal, self-harm and suicide.
(Humanity & Inclusion Iraq, "Health Technical Strategy 2023-25")

There are no health services, playgrounds, or schools close to where Shaha’s family lives. Children struggle to reach school in the winter months as the streets are muddy and unpaved. Sometimes Shaha cries saying that she does not want to go to school because she has to walk a long way.

While humanitarian NGOs have been responsive to Shaha’s needs, out-of-pocket expenses to cover medication and transport costs are a significant burden on the household.  These costs are not likely to be reduced in the future. Shaha’s health conditions require regular medical follow-up, and additional eye surgery at an older age. One of Shaha's brothers has a brain tumour, resulting in severe brain damage and requiring multiple surgeries. In addition to the health-related costs, Shaha’s mother says that the healthcare worker shortages cause long waiting lists, even for a simple blood test.

Despite the existing programmes to support persons with disabilities and their caregivers, many persons with disabilities are unable to receive social protection payments.
In order to apply, people must first access a centrally-located centre, and then be assessed as having the required “level” of disability (expressed as a %), which involves several trips and complicated procedures.
Therefore, persons with disabilities often rely on NGOs for their basic needs.
(Action Against Hunger, "Accessing social protection in Iraq: Mapping of program and analysis of barriers", 2023 AND Humanity & Inclusion Iraq, "Health Technical Strategy 2023-25")

The family remains strong and close.  Shaha's older brother is a guiding light. They have called him “baba” (dad) ever since their father died. He is a high-achieving student in his second year of anaesthesiology, and has great ambitions to support his family to the best of his ability. 

Mr Dee is a mechanic, husband, and a father of two children under the age of five. At 16, he was riding on a motorbike with his cousin to reach a farm where they had found work in an area known for its bending and steep roads. The brakes of his motorbike didn’t work properly, and he could not avoid hitting the concrete safety barriers alongside the road.   

In Lao PDR, annual crashes rose by 35% between 2010 and 2020, and the number of fatalities increased by 67% to reach over 1,000. The accounts of crash survivors are testimony to the severe impact of accidents on personal health and family finances. (World Bank, PRESS RELEASE NO: 2022/030/EAP, 2021).

He felt no pain when lying on the road. However, when he tried and failed to stand up, he realized that there was a serious problem.
Luckily, his cousin was not injured. He placed Mr Dee in a safe place by the side of the road and drove on the motorbike to Mr Dee’s family home to alert his parents about the accident. The parents arranged a car, picked up their son and drove him to the nearest hospital, which was four hours away. The doctor immediately stated that he needed his left leg amputated, just below the knee. 

“I didn’t know anything about amputation and disability. I was very concerned about my future, especially whether I would be able to work and get married.”

In addition, he felt guilty because of the disappointment he thought he was causing, since the eldest son is traditionally expected to take care of the whole family. During the month he spent in hospital, he lay in bed all the time and never received nor was told about any psychosocial support, prosthetics or rehabilitation service. He fell into a deep depression. He hardly left his bedroom once back at his parents’ home. Very few friends came to visit him.

Luckily, his cousin, who is in the army, told him about the rehabilitation services provided in a bigger and more distant hospital. It took almost a year for Mr Dee’s family to take him to the rehabilitation centre, a significant length of time considering the impact of amputation on a young man’s psychological and physical wellbeing.

While the medical and transport costs were covered by the public system, the transport costs were only reimbursed after the first appointment at the hospital, and the accompanying people had to pay for themselves. This cost around 200 USD for Mr Dee’s father, who stayed with him for two weeks at the centre. Only after a year, when Mr Dee’s family had managed to raise this amount of money, did they visit the rehabilitation centre to get his prosthetic leg fitted.
 

In conflict-affected countries, rehabilitation services and provision of assistive technology are often designed to respond to the needs of veterans and/or victims, as occurred in the aftermath of the Laotian Civil War (1959–1975).

However, victim assistance frameworks refer specifically to the fact that there should be no discrimination against or among victims, or between survivors and other persons with disabilities, who should benefit from services in the same manner.

By improving functioning, rehabilitation and assistive technology increase access to education, social engagement, and work activities, greatly contributing to the individual’s ability to participate in multiple spheres of life.

The return on investment is significant: for every dollar invested in assistive devices, there is a return of nine dollars (Global Partnership for Assistive Technology (2020). The Case for Investing in Assistive Technology.)

In 2020, with the support of Humanity & Inclusion, he managed to acquire business management skills and open his own garage, on the ground floor of the building where his family lives, in a busy street of the provincial town of Sam Neua. He also receives help to continuously access rehabilitation. Indeed, Mr Dee needs a new prosthetic leg roughly every two years, which involves a one-week stay in hospital each time.

He is very satisfied with his business, as he has a lot of loyal customers. And most of all, he is proud that he can support his parents, as a good first-born son is expected to do.

Launched from the ground or dropped from the air, cluster munitions consist of containers that open and disperse submunitions indiscriminately over a wide area. Up to 40% fail to detonate on impact. Then they become de facto land mines that kill and maim indiscriminately long after the conflict has ended. The Lao People’s Democratic Republic (Lao PDR) has the world’s highest level of contamination by unexploded cluster munition remnants, resulting from aerial bombing raids carried out by the United States (US) from 1964–1973 amid the Second Indochina War. (Landmines Monitor 2023)

Mr Ngok is now 38, is a farmer and lives in the rural Houameuang district (in Northern Lao PDR) with his wife and children. “It was really hard to do the heavy work in the fields with one hand”, he says. Indeed, Mr Ngok had to wait almost 20 years before he could access the rehabilitation services and devices that he needed.

After the accident, the doctors removed only his fingers at first; but the limb was damaged by chemicals contained in the weapon, and they had to amputate the whole hand in subsequent surgeries. 

Mr Ngok remembers the feeling of desperation when he understood that his right hand was gone. The support from his parents and the doctors, and seeing other children in the hospital who had been injured like him, convinced him that he would be able to continue his life.
During the month he stayed in hospital, he was not told about and did not receive physiotherapy, prosthetics, or any other rehabilitation services or devices.  

 In Lao PDR, rehabilitation is offered primarily at central/ provincial hospitals and in rehabilitation centres. In general, MOH does not provide rehabilitation at district hospitals. There have been efforts to provide a service at community level, but these remain limited in scope and geographic reach.
(Lao PDR Ministry of Health, with support from the United States Agency for International Development and the World Health Organization, "Systematic Assessment of Rehabilitation Situation in Lao People’s Democratic Republic", 2018.)

He went back to school, determined to continue studying and adapt to the loss of his right hand. Despite the sometimes hostile environment, with harsh comments from classmates and neighbours, he managed to continue studying until he was 18. He was already 27 when he received help to access rehabilitation services for the first time. He was referred by village authorities to the Provincial Rehabilitation Centre, a four-five hour drive from his home. He stayed in the centre for two days while he received his first prosthetic arm.  

The device did not have many features, but it did give him confidence: “I could wear it at parties and outside of my village, without people knowing that I was an amputee”, he recalls with a broad smile. He has had three different prostheses over the past 11 years.  In 2023, he received his latest one, a 3D printed prosthetic arm with an adapted attachment, from the Provincial National Regulatory Authority. He hopes for an even more functional device in the future in order to become more independent in his daily life. 

Policy frameworks have been developed over the years to guide the response to rehabilitation needs and victim assistance. The Lao PDR National Rehabilitation Strategy 2018-2025 aligns with WHO’s global and regional actions.
Victim assistance has a dedicated policy framework for the 2022-26 period, and is integrated into Safe Path Forward III 2021–2030 and the Multi-Year Workplan 2022–2026 (Landmines Monitor 2023.)

Looking back, he is very thankful for the services he was able to access, but also thinks about those people whose needs are not yet met.

“There are a lot more people affected by UXO in Lao PDR. Every UXO survivor should have information on and access to rehabilitation services, especially in the most remote areas.”

He is still not able to access all the services he needs. His eye was damaged in the explosion, and some shrapnel fragments still remain under his skin today. Although there is free eyecare at the district level, he was not referred to the appropriate services, and he could never spare the time and resources needed to travel to the district capital to get his right eye checked. Financial accessibility is indeed a concern.

Mrs Xoua Xiong is 33 years old and lives in a rural Hmong community in Houameuang district. Mrs Xoua Xiong and her husband grow rice and corn, and breed chickens, pigs and goats to support their six children. They work as daily labourers on other farms when their earnings are low. As a child, she used to work in the fields with her father and brother. They did not know that the land was contaminated by unexploded ordnance (UXO).  

Unexploded ordnance (UXO) contaminates nearly 25% of the country’s villages. (Lao PDR Ministry of Health, with support from the United States Agency for International Development and the World Health Organization, "Systematic Assessment of Rehabilitation Situation in Lao People’s Democratic Republic", 2018.) Over the past five years, an average of 50–60km of cluster munition contaminated land has been released annually. Lao PDR’s Multi-Year Workplan for 2022–2026 aims to release 500km (Landmines Monitor 2023.)

Mrs Xoua Xiong was severely injured in a UXO accident when she was doing farm work at the age of nine. She remembers the long journey to the provincial hospital where surgeons amputated her right arm below the elbow: 

“I was first carried to my house, then it took hours for my parents to reach the main road where my father could rent a truck and drive me to the hospital.”

63% of the Lao population lives over 100km from a rehabilitation centre. (Humanity & Inclusion, "iFAR Diagnosis (Improving financial access to rehabilitation services) -Analysis of the economic system of functional rehabilitation in Lao P.D.R", 2015 and updated in 2018)

She went home in severe physical and emotional pain three days after the amputation. She had to undergo a second surgery because the physical pain intensified. At the time, her family received some financial support from an international NGO, but they were not informed about the available rehabilitation services or assistive devices. 

Furthermore, she had to contend with the negative reactions of some members of her family and of the community, who did not want to interact with a girl with an amputated limb. However, her teachers and the other students at school were supportive. For example, Mrs Xoua Xiong recalls that they did not ask her to take part in activities that she could not undertake, such as cleaning the school. Nevertheless, she felt very different from the other children: “I did not like going out, I preferred to play alone and spend time on my own”. 

Years later, when she was 13, she received her first prosthetic arm at Xian Khouang Rehabilitation Centre, after being identified by village authorities and supported by a non-governmental organisation. 

Across large parts of the world, girls and women of all ages with any form of disability face multiple forms of discrimination and inequalities, driven by multiple (and overlapping) attitudinal barriers, prejudice and stereotypes. (UNDP Asia and the Pacific, 'Understanding and tackling intersectional stigma experienced by women and girls with disabilities ", 2022.)

In 2022, Mrs Xoua Xiong received a 3D prosthesis from the Provincial National Regulatory Authority.

In the case of a UXO incident, the National Regulatory Authority’s victim assistance unit provides follow-up and links to operators to ensure the delivery of essential support.
(UNDP, “Background paper for UXO donor and media field visit, 31 March–2 April 2021,” April 2021.)

She says that the device was too tight, as Mrs Xoua Xiong was slimmer at the time the measurements were taken. She barely uses the device now: “it helps with my daily work and small tasks, but it does not have all the functions of a real arm and it does not help me carry heavy loads”.  Without external support, Mrs Xoua Xiong does not know how to get a referral to a rehabilitation centre to adapt her prothesis, nor how to cover transport and accommodation costs.

In Lao PDR, rehabilitation at district and community levels is very limited, and case management /referral pathways are underdeveloped.
(Lao PDR Ministry of Health, with support from the United States Agency for International Development and the World Health Organization, "Systematic Assessment of Rehabilitation Situation in Lao People’s Democratic Republic", 2018.)

As an adult, she still feels very different from the other women, and thinks that some people in her village do not respect her because of her impairment. She is grateful for the support given by some organisations to persons with disabilities, and that she can count on the support of her husband, who says: “she is my wife and I love her. I don’t care if she can’t do the same work as other people.”