Perspectives from Ghana - The International Society of Physical and

Report
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
Outline

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
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
Principles of humanitarian emergencies
Rehabilitation medicine perspective
Conflict in Sub-Saharan Africa
Conflict in Ghana (and our neighbors)
Available rehabilitation resources
Conclusions
Thought framework
Worldwide

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Natural disasters
Man-made
conflict/occupational
catastrophe
Strike suddenly
Unfold gradually
Increase risk of resource
shortage (arable land, food)
Disproportionately impact
vulnerable groups
Africa




Political instability
Chronic simmering conflict
Human trafficking and child
soldier recruitment practices
Deep poverty
USAID
United Nations Office for the Coordination of Humanitarian Emergencies
World Vision Africa
Numerous players often provide
collaborative solutions
Humanitarian
Organizations
Military
Organizations
Local Physical
Resources
Non-Governmental
Organizations
Development
Organizations
Local Human
Resources
Image: Conflicts in Africa 2000-09, P.D. Williams, War and Conflict in Africa (Williams, 2011),
Principles and goals of rehabilitation
are shared among aid groups
Humanitarian
Organizations
NGO’s
Development
Organizations
Principles:
 Humanity
 Impartiality
 Neutrality
 Independence
Principles:
 Humanity
 Impartiality
 +/- Neutrality
 +/- Independence
Goals:
 Alleviate suffering
(short term)
 Re-establish choice
REHABILITATION
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
PASSABLE ROADS
FUNCTIONAL VEHICLES
HOSPITALS
SANITATION, DME, SHELTER
TRAINED PERSONNEL
TELECOMMUNICATION
Sub-Saharan Africa suffers extreme
and unique poverty
Nation-states characterized by average life expectancy (2012)
Severe
Poverty
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)
Orientation to Ghana
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
Ghana is sandwiched by conflict
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
Nigeria:
Recurrent political
and resourcerelated conflict,
small and large
Liberia:
Two “successive”
civil wars to 2003;
displaced many;
refugee status to
be removed
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
redistribution
state investments)
KosmosofEnergy’s
2007 discovery of an
oilfield has led
to an influx of
 Partisanoff-shore
politics (asymmetric
representation
of ethnic
foreign interest
placing the manufacturing
heterogeneity
in government)
industry at risk and has challenged our
 Deep poverty (limited economic, emotional, reserve)
track record of amicable foreign relations
and Nation-States
good governance
West African
remain at risk

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
PASSABLE ROADS
FUNCTIONAL VEHICLES
HOSPITALS
SANITATION, DME, SHELTER
TELECOMMUNICATION
TRAINED PERSONNEL
Tro-tros are crowded and inaccessible
Public facilities are 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
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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
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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
Conclusions
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
Poverty
“…impairments, activity limitations &
participation restrictions. It denotes the
negative aspects of the interaction between
an individual (with a health condition) &
[their] contextual factors…”
Non-monetary factors (education, health,
living conditions) and monetary factors
(income versus consumption expenditures,
individual & household assets)
Health
expenditures
Cultural factors
(stigma)
Environmental
factors
Personal factors
Low income
Full
participation
in society
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)
Removing barriers enables full
participation in society
Disability
Poverty
“…impairments, activity limitations &
participation restrictions. It denotes the
negative aspects of the interaction between
an individual (with a health condition) &
[their] contextual factors…”
Non-monetary factors (education, health,
living conditions) and monetary factors
(income versus consumption expenditures,
individual & household assets)
Health
expenditures
Cultural factors
(stigma)
Environmental
factors
Personal factors
Low income
Full
participation
in society
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)
Relationship between disability and
poverty remains tangled
Disability
Poverty
Health
expenditures
Low income
Cultural factors
(stigma)
Poor sanitation
Environmental
factors
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)
Risk situations and emergencies further
stress this reserve-limited system
Disability
Poverty
Health
expenditures
Low income
Cultural factors
(stigma)
Poor sanitation
Environmental
factors
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)
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

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