1. Physical Rehabilitation & Humanitarian Emergencies: Perspectives from Ghana November 2012 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

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

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

4. 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

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

6. 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

7. 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

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

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

10. 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) 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

11. 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

12. 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”

13. Ghana enjoys a stable socio-political climate but it’s neighbors do not Cote d’Ivoire: 2010 political impasse (Gbagbo v. Outtara) led to post-electoral v 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 resource- related conflict, small and large World Vision Africa United Nations Office for the Coordination of Humanitarian Emergencies

14. 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) 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 West African Nation-States remain at risk

15. 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 of state investments)  Partisan politics (asymmetric representation of ethnic heterogeneity in government)  Deep poverty (limited economic, emotional, reserve) The Economist (1977) West African Nation-States remain at risk Kosmos Energy’s 2007 discovery of an off-shore oilfield has led to an influx of foreign interest placing the manufacturing industry at risk and has challenged our track record of amicable foreign relations and good governance Neubauer C (2010) “Ghana discovery sparks fight over oil” in The Washington Times, http://www.washingtontimes.com/news/2010/mar/26

16. 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

17. 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 Tinney MJ et al. (2007) Medical rehabilitation in Ghana Dis Reh 29(11-12):921 Haig AJ et al. (2009) The practice of physical medicine and rehabilitation in sub-Saharan Africa and Antarctica, International Rehab Forum Christian A et al. (2011) Rehabilitation needs of persons discharged from an African trauma center, Pan Afr Med J 10(32)

18. 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

19. Tro-tros are crowded and inaccessible

20. Public facilities are inaccessible

21. 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”

22. 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

23. 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 Ghana National Disaster Management Organization United Nations USAID

24. 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

25. END

26. 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.

27. Disability (and poverty) is a bio- psychosocial construct “…impairments, activity limitations & participation restrictions. It denotes the negative aspects of the interaction between an individual (with a health condition) & [their] contextual factors…” Disability Non-monetary factors (education, health, living conditions) and monetary factors (income versus consumption expenditures, individual & household assets) Poverty Full participation in society Environmental factors Personal factors Under education Chronic, poor health Poor sanitation Low income Health expenditures Cultural factors (stigma) 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)

28. Removing barriers enables full participation in society “…impairments, activity limitations & participation restrictions. It denotes the negative aspects of the interaction between an individual (with a health condition) & [their] contextual factors…” Disability Non-monetary factors (education, health, living conditions) and monetary factors (income versus consumption expenditures, individual & household assets) Poverty Full participation in society Environmental factors Personal factors Under education Chronic, poor health Poor sanitation Low income Health expenditures Cultural factors (stigma) 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)

29. Relationship between disability and poverty remains tangled Environmental factors Personal factorsUnder education Chronic, poor health Poor sanitation Low income Health expenditures DisabilityPoverty Cultural factors (stigma) 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)

30. Risk situations and emergencies further stress this reserve-limited system Environmental factors Personal factorsUnder education Chronic, poor health Poor sanitation Low income Health expenditures DisabilityPoverty Cultural factors (stigma) 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)

31. Foreign presence includes eight sub- region “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

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

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