Situation Analysis

The United Nations High Commission for Refugees considers displaced people to include refugees and Internally Displaced People (IDPs). Refugees are defined as "people who are outside their countries because of a well-rounded fear of persecution based on their race, religion, nationality, political opinion, or membership in a particular social group" (UNHCR 2007). IDPs face similar circumstances but live within the borders of their country. The UN agency estimates that there are 32,861,500 refugees in the world. Of these, 9,752,600 are in Africa and 2,105,314 are to be found in the East African region, a region that has for long been torn in protracted war and civil strife, especially in Sudan and Somalia (UNHCR 2007).

A large segment of displaced people is disabled, and faces serious challenges. The UN figures tell us that mortality for children with disabilities can be as high as 80%. They are often the last to receive food or medical care but they are the first to die. In terms of child protection, girls with disabilities are three times more likely to be sexually abused than girls without disabilities. In most cases, poverty leads to disability and disability leads to poverty. The World Bank estimates that people with disabilities comprise about 20% of the 'poorest of the poor.' People with disabilities are less likely to receive education and therefore less likely to work, which further leads to poverty. Poor people are unlikely to access medical care and thus are likely to become disabled by injury, illness, or disease. Thus people with disabilities are denied the most basic of human rights (see CBM website).

Disability and displacement go hand in hand. Displacement is accompanied by many related casualties, including disability. The main causes of disability among displaced persons arise from the fact that some of the victims may have served as soldiers, guerrillas, or other combatants and suffered physical and psychological trauma, including amputations and injuries from mines. Others have witnessed their close relatives and friends being tortured, maimed, killed, or raped. Others again have endured flight through thick forests. This results in many kinds of disabilities, including physical and mental impairments. Illness and congenital causes play a role in others. According to the US Committee on Refugee and Immigration (USCRI, 2006), many of the refugees resettled in the US have one or more disabilities. This is because many have lived in poorer regions of the world where armed conflict and related injuries are common.

In refugee situations, disabled children and adults are particularly vulnerable. Without independent mobility, families fleeing danger may be forced to abandon them, exposing PWDs to more health and safety risks and reducing their chances of survival. For those who may manage to reach refugee camps, the situation in the camps gives rise to an increase in causes of impairment through poor nutrition and health conditions, injuries relating to conflict, accidents, burns, torture, and trauma.

The fact that refugees are settled in emergency situations means that little thought is given to refugees with disabilities in the camps. Emergency arrangements typically fail to address the specific needs of people with disabilities, either in buildings or provision of essential social assistance. Their existence and needs are rarely acknowledged. In the daily running of the camp, they are often the last to receive food, water, and care as they may not be able to access food and water distribution centres or even the health centres (Refugees International, 2003). Lack of housing, personal care needs, and communication difficulties add to their problems.

Despite their heavy presence in refugee camps, little is known about their true numbers or how they cope. However, WHO estimates that between seven and ten percent of the general population live with disabilities.

The majority of disabled people face poverty and discrimination. However, disabled refugees face double vulnerability: "They are among the most marginalized in an already disposed group" (Refugees International, 2003). The plight of disabled refugees is heightened by the fact that no legal instruments exist at an international level to protect the rights of disabled refugees. Disabled refugees can only refer to scattered provisions of conventions, legal instruction, and international humanitarian law (HARP 2003).

In 2006, Kenya had a refugee population of over 314,600, mainly in the Dadaab and Kakuma camps (IRC records). The camps are located in areas with very dry and hot weather, where even the local community subsists with difficulties and depends predominantly on relief food. Thus hostilities between the local communities and refugees abound, as the former view the latter as privileged due to the assistance they get from charitable organizations. In this connection, implementing partners always provide some services to the local community to decrease these hostilities.

Disabled refugees in Kenyan camps face many problems. According to Handicap International, one of the implementing partners dealing people with disabilities, although efforts have been deployed by international agencies to meet their basic needs, persons with disability and their families suffer daily discrimination, stigma and violence issues, face permanent access and mobility difficulties, get little access to adequate services, and rarely have a voice in the camps, community leadership, and committees.

However, according to UNHCR, although some disabled refugees may require physical therapy, physical aids, or prosthetic devices, special needs of the vast majority can be met via fairly minimal, economic interventions. Many refugees may just need a walking cane, a knee brace, or therapeutic walking shoes. Other services will include rehabilitation care and counselling, general public awareness campaigns, and promotion activities for mainstreaming disability issues into all sectors in the camps.

Disability also presents a challenge during repatriation back to their home countries. In the case of Sudanese refugees in Kakuma, while it is possible to use a wheelchair in the Kakuma camp, crossing temporary bridges through forests and narrow footpaths is a nightmare for disabled people. They face many problems during repatriation and are at the mercy of relatives, if they have any. Back in Sudan, those with mental disabilities are kept together with the mentally sick in hospitals, as their case is not properly understood.

Other factors affecting service delivery for disabled refugees include:

  • Lack of visibility: In general, disabled refugees are rarely acknowledged. They are not given a chance to be heard. Their existence is rarely acknowledged, and for them to benefit from health and nutrition programs, these programs need to address the needs of PWDs.
  • Disability awareness: There is little knowledge, skills, and awareness about disability among those who manage the refugee situations. Therefore buildings are designed without PWDs in mind. Personal care in terms of mobility and communication gadgets, aids, and adaptations are not taken into account either.
  • Communication: Many people are not educated or empowered to communicate in sign language or Braille and find it extremely hard to interact with people with disabilities.
  • Disabled refugees' lack of awareness on rights: Many disabled refugees are not aware of their rights and are therefore unable to demand these rights.
  • Lack of proper data: There is lack of data on the number of refugees with special needs. Nor are PWDs placed in different categories. It is therefore difficult to plan for them.

International Rescue Committee's Response.

IRC's refugee program focuses mainly on the Kakuma Refugee camp in the Northern Turkana District of Kenya. Kakuma was founded in 1992 as a safe haven for the 17,000 "lost boys" of Sudan. Currently, Kakuma hosts about 70,000 refugees from 8 countries, mainly from Sudan and Somalia. Programming in Kakuma recognizes the need to take care of disadvantaged groups according to international human rights conventions. In line with this, IRC runs a Community Based Rehabilitation (CBR) program, a Curative/Mental Health Program, and a Special Needs Education program to help assist those with disabilities.

Disabled children in the Kakuma Refugee Camp comprise those with mental impairments, physical disabilities, hearing impairments, visual disabilities, and learning and cognitive disabilities. In 2000 and 2003, the IRC undertook two Disability Prevalence Surveys in the Kakuma Camp. The results confirm that a significant number of refugees suffer from disabilities. As many as 6.8% of the refugees have a recognized disability. Of these, 51% are physically disabled, 26% are visually impaired, 16% have hearing impairments, and 10% have learning and cognitive deficits. In addition, in 2004 a total of 125 persons with developmental disabilities (PWDDs) were identified through CBR's assessment of persons with disabilities. (references) The results of these studies have helped to highlight the need for IRC and other stakeholders to meet the full range of needs of refugees with disabilities. Furthermore, as the repatriation of the Sudanese refugees continues to take place, it is important to build their coping mechanisms and life skills as much as possible to contribute to a smooth and successful repatriation.

Specific activities undertaken by IRC on disability interventions include:

Special Needs Education.

IRC has an ongoing Special Needs Education Program (SNE) that has successfully mainstreamed over 400 pupils into regular schools through targeted individual education programs. 122 of those students had mental disabilities of various levels. The Centre for Basic Occupational Therapy (CEBOT) and Rehabilitation Workers are used as referral points to identify those who require individual education programs so they will eventually be able to join mainstream education with their peers.

In some cases, where children are severely mentally disabled, the level of disability prevents placement in schools. Instead, a teacher aide will make two or three home visits each week and will work with the child on special activities — for example, using colored blocks, learning basic hygiene, such as using the latrine, and ways to help at home. The programs are customized for each individual and state the beneficiary's current level of performance, the annual goals, short-term goals, and the specific education and related services that should be provided. Progress made towards the beneficiary's goals is regularly monitored.

Even if they are unlikely to complete school, with training, many of those with mental disabilities can very often become extremely productive at certain jobs, such as brick making, bead making, or fish-net weaving. Learning these types of skills will allow them to become contributing members of their community rather than a perceived burden on their families. Even if paid employment is not possible, the assistance that the SNE program provides in other areas, such as personal hygiene and helping children to learn how to help at home in basic cleaning, reduces stress on the family and helps the disabled children contribute to family and community.

Community Based Rehabilitation (CBR) program

IRC runs a community based rehabilitation program that offers:
  1. Home-based care services.
  2. Physiotherapy and occupational therapy services.
  3. IRC's CBR program specifically organizes the following activities:
  4. Identifies, assesses, and registers people with disabilities in the community.
  5. Imparts some vocational skills, i.e. bicycle repair.
  6. Designs and implements ITPs for the identified patients.
  7. Refers all patients on the register, as per needs assessment, to various services, including orthopaedic, physiotherapy, nutrition, clinics, education, JRS, VCT, CEBOT, eye clinic, and hospitals.
  8. Procures and repairs tricycles for use by the PWDs.
  9. Fabricates of a variety of specifically recommended low-cost adaptive, stimulation, and mobility devices.
  10. Teaches orientation, mobility, and activities for daily living to visually impaired persons.
  11. Conducts community awareness workshops on the rights of persons with disabilities.
  12. Conducts monthly group therapy sessions for PWDDs and their family members/guardians.
  13. Conducts Children's Support Group sessions for CWDs.
  14. Provides physio/occupational therapeutic services to all deserving physio-orthopaedic clients and keeps records. The program gives basic occupational therapy treatment and rehabilitation to identified and/or referred patients at the CEBOT.

Referrals to Medical Services

The IRC Community Based Rehabilitation program identifies PWDs and refers them to health facilities for physiotherapy and ortho-surgical services. Those PWDS identified as requiring medication in the management of their illness will be referred to the Kakuma Camp Hospital and three clinics. At each of the three clinics, IRC has a mental health office in which patients requiring medication for mental health problems are monitored by IRC Mental Health staff. Those who require corrective surgery are referred to Bethany Kids of Kijabe Hospital.

Physical Therapy

The Centre for Basic Occupational Therapy (CEBOT) was funded by the Jean Kennedy Smith Foundation in the United States. It entailed setting up and equipping a Centre for Persons With Developmental Disabilities (PWDDs) and training rehabilitation workers who will assist PWDDs to develop their fine and gross motor skills. The role of the rehabilitation workers is to help those with developmental disorders in the areas of self-care, recreation, and work. They also have overall responsibility for monitoring the progress of the beneficiaries and ensuring that they receive all services available to them. The rehab workers are scheduled to work at the CEBOT and undertake home visits, especially for those PWDDs who are unable to access the CEBOT. They help to identify practical solutions to a range of physical problems by using tools, toys, appliances, and utensils. Specific activities focus on areas such as balance, posture, tactile discrimination, motor planning, and coordination. Each trained staff (with assistance from volunteers) assists approximately fifteen PWDDs. The CEBOT is equipped to offer physical therapy to children. Currently, about 200 children are accessing the service. Physical therapy is an important part of improving the beneficiary's strength, endurance, and range of motion. Physical therapy is used to prevent, correct, and relieve physical conditions with the use of heat and cold treatment, massage, splinting, and exercise. IRC has a physical therapist and trained staff who attend to the Rehabilitation Center in order to assist and treat beneficiaries as well as provide some basic training to family members. If a beneficiary is unable to access the Rehabilitation Centre, the physiotherapy team attends to the beneficiary at his/her home. Rehabilitation workers are responsible for referring the beneficiary to physical therapy services.

Family Therapy

Frequently, family members feel helpless and stigmatized when one of their own has a developmental disability. They often go through a series of psychological stages (shock, denial, bargaining, anger, depression, and acceptance) and it is imperative that the family is helped through this process, with access to appropriate support networks. In order to make this support available, IRC offers family counselling, workshops, and family support meetings at the Rehabilitation Center. IRC has trained some staff on basic counselling skills (Life Skills Trainers). The staff are based at the Rehabilitation Center but also undertake outreach activities with the community, beneficiaries, and family members. Training is also offered to family members who act as caregivers for their disabled kin. It focuses on helping the caregivers understand how to assist with education, physical therapy, and life skills development. To ensure that the training is successful, special care is taken to ensure sensitivity towards family members' goals, abilities, and culture.

Two therapy groups of parents/family of CWDD have been formed — those with cerebral palsy as well as the moderate/severely disabled children meet frequently to discuss issues and comfort each other.

Life Skills Development

To ensure beneficiaries reach their full potential, help them become more productive family members, and reduce the burden on the family, IRC offers individual training plans, focusing on life skills development in areas such as personal hygiene and home skills. This is done both at the Rehabilitation Centre and at the beneficiary's home. The individual activity plans are mapped out so they target the areas where the beneficiary shows most potential, or where they seem ready to move forward. This activity is undertaken by the life skill trainers, who are provided with the necessary skills.

Community Sensitization

IRC undertakes sensitization for community members on issues of PWDs aimed at reducing stigmatization in the Kakuma Refugee Camp. This is done through awareness sessions carried out in many different types of community settings, such as workshops, trainings, meetings with community leaders, and during events such as the International Day for the Disabled. Such awareness creation enhances understanding of PWDDs and their acceptance in the community. Role models with disabilities are used to motivate the community and reduce stigma.

Linkages

The IRC has linkages with organizations both within the camp and outside, which ensure that the most comprehensive and up-to-date packages are offered to PWDD's. These include:

Jesuit Refugee Services (JRS)

JRS operates a 'Safe Haven' in the Kakuma Refugee Camp. The 'Safe Haven' is for people in times of distress who require counseling (they have a trained psychologist on staff) and a sense of security. IRC's CBR program refers PWDs who can benefit from counseling to the 'Safe Haven.'

World Food Program (WFP) and Lutheran World Federation (LWF)

WFP and LWF are responsible overall for the food distribution in the Kakuma Refugee Camp. Considering the vulnerable nature of PWD's, IRC advocates for fair and indiscriminate food rationing for PWDs. This is done via information and awareness raising between IRC and WFP/LWF as well as directly requesting for assistance for PWD's if cases of discrimination are found.

Government of Kenya

The Kenyan Ministry of Education has a program called Educational Assessment and Resource Services (EARS). The main objective of EARS is to ensure correct placement of children with disabilities into mainstream schools. It also offers a home-based care service to those who may not directly benefit from such educational placement. Turkana District has its EARS Centre in Lodwar. IRC and EARS have been working together in the following areas:

  • The CBR Program currently uses the test materials from this Centre.
  • The questionnaires used by the CBR team is sourced and improved on from the EARS program.
  • CBR clients are also referred to the Turkana Assessment Centre for audiometric tests to measure hearing.

Networking meetings have taken place between EARS and the CBR program to further explore the opportunities for cooperation in assessment work, with a view to preparing CBR assessment services for sustainability.

Bethany Kids of Kijabe Hospital (BKKH)

IRC refers clients to BKKH, some of whom are PWDs. The Centre treats these clients, especially those requiring corrective surgery. Through its Occupational Therapist, it also provides IRC with training notes for the clients after they have been discharged. This is in order for IRC's CBR program to follow up with the clients once they have returned to Kakuma to ensure they are following out the program advised for them. The Occupational Therapist also travels to Kakuma four times a year to follow up on the clients and monitor the progress.

Lessons Learned and Suggestions

Given a chance to be heard, disabled refugees will offer possible solutions to problems afflicting them. To enhance their voices and quality of life, here are a few suggestions:

  • Make disability a visible issue and ensure that persons with disabilities participate in planning camp programs. This should be a policy in all camps.
  • Sensitize camp managers on the needs of different categories of persons with disabilities and how best to meet them.
  • Encourage parents of disabled children not to hide them but bring them out to benefit from rehabilitation, education, and health and nutrition programs. They will benefit greatly from ordinary programs in the camp.
  • Provide employment (incentive work) to persons with disabilities. The main problems for disabled people are often the attitudes and lack of awareness from other people, rather than the impairment. For many disabled people, what they need is a job, leading to self-reliance.
  • Provide more rehabilitation services (exercises, mobility, aids, prosthetics, hearing aids, Braille, etc.) in order to transform the lives of people with disabilities, thus enabling them to become contributors to the community.
  • Offer more regular basic training for teachers in addressing special needs, enabling the teachers to become more effective with all children. With such training, children with disabilities will benefit more from mainstream education.
  • Establish disability services in mother countries to facilitate repatriation and reintegration back home. This will ensure a smooth transition and encourage people with disabilities to return home.

These initiatives will contribute greatly to ensuring that basic rights for persons with disabilities in contexts of displacement are met.

Works Cited

  • Health for Asylum Seekers and Refugees Portal 2003: http://www.harpweb.org.uk/
  • Christian Blind Mission: http://www.cbmi.org.au/
  • International Rescue Committee 2007: Kenya Adult and Special Needs Education Program Evaluation Report. IRC Kenya, Nairobi Office.
  • International Rescue Committee 2007: Kenya Quarterly Reports. IRC Kenya, Nairobi Office.
  • Refugees International (RI) 2003: Displaced and Disabled: http/www.reliefweb.int/
  • UNHCR 2007: Global Trends; Refugees, Asylum Seekers, Returnees, Internally Displaced and Stateless Persons: http://www.unhcr.org/
  • USCRI 2006: World Refugee Survey. US Committee for Refugees and Immigrants: http://www.refugees.org/
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Copyright (c) 2009 Michael Karanja



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