REHABILITATION IN CONFLICT ICRC CASE STUDY RESPONSE CHALLENGES & SOLUTIONS WHO REHAB 2030 MEETINGS JULY 2019 Mohammed Saleh • 29 years old • Bus driver in Aden before onset of Yemen civil war • POW for 7 months in the battle of Aden (2015) • Traumatic brain injury following GSW in 2017 Images: PRP ICRC, Aden 2017: Gunshot wound in Al Mokha No memory of the event Map from: https://commons.wikimedia.org/wiki/File:Yemeni_Civil_War.svg War Surgery. Working with limited resources in armed conflict and other situations of violence. Volume 2. ICRC, May 2013 Images: PRP ICRC, Aden 3 weeks in coma in hospital in Aden - Surgeon didn’t want to operate because low survival chances Map from: https://commons.wikimedia.org/wiki/File:Yemeni_Civil_War.svg Regained consciousness after 2 weeks - Memory loss, uncontrolled emotions, impulsive behavior (no psychologist) - Expressive aphasia (no speech therapist) - Hemiplegia (3-4 short sessions of physio only receiving some stretching) Map from: https://commons.wikimedia.org/wiki/File:Yemeni_Civil_War.svg 36 days of rehabilitation treatment in Egypt - 1,5 h of physio per day (after 5 weeks hospitalization in Yemen) - Sit-to-stand with a lot of support - Functional training - still: some inappropriate behaviour, memory loss (no psychologist) - very slow speech recovery (no speech therapist) Map from: https://commons.wikimedia.org/wiki/File:Yemeni_Civil_War.svg Return to Yemen - 6 months physio in private practice, electrotherapy only - No progress, feeling miserable - Start of rehab in ICRC-supported structure 9 months after injury Map from: https://commons.wikimedia.org/wiki/File:Yemeni_Civil_War.svg Main problems & goals at start of rehab in ICRC-supported center Current rehabilitation treatment Images: PRP ICRC, Aden Images: PRP ICRC, Aden AFO: gait speed, fluency, weight bearing, safety, energy expenditure Videos: PRP ICRC, Aden Videos: PRP ICRC, Aden ICRC supported centre Aden • Task-based rehab • Team of PT, P&O, doctor, social worker • ‘Microcredit expert’ to promote social inclusion • PT Staff: mix of PTAs (14), on-the-job trained assistants (8) and 1 Expat PT ........ • Still no SLT, OT, neuropsychologist • Resource intensive: tailor-made AFO, equipment, staff • Unfunctional UL orthosis Mohammed and UHC • High quality Mixed, mainly poor • According to need (evidence-based) • With no financial High out-of-pocket hardship expenditures The complexity of protracted crises overall uncertainty, poverty, corruption situation health health system dysfunctional; pre-existing, conditions changing developing/deteriorating, interlocutors accumulated trauma security needs urgent increased tense, unstable, unpredictable complex cultural infrastructure concepts paralysing destroyed education system staff Left, killed - fragile insufficient, unqualified social economy/ system barely existing markets collapsed What needs to change? What is realistic? Early start Security, availability, access, awareness Timing & coordination of Minimum standards, rehab domains competencies & task-shift Dosis Minimum standards, research Clear roles for each staff competencies & task-shift member Evidence-base Needed! Government Advanced practitioner International organisations? Rehab professionals (OT, PT, P&O, etc) Mid-level workers (assistants, technicians, CBR workers) Self-management, family, nursing staff Training Professional institutions associations Strategies & solutions • Think big • Improvise • Include Strategies & solutions 1. Have ultimate goal of rehab in mind from day 1 • FUNCTIONALITY • ADL independence • participation/reintegration 2. Improvise • identify key players in each individual’s rehabilitation process • ‘task shifting’ • posters, brochures, key messages, dos & don’ts, pictograms 3. Include all • patient • family • other health team members • If existing: gvt structures, training institutions, prof associations ... • Measure outcome, collect data, design research Thank you Acknowledgements Maarten Abeel Huda Abdullah Saif Bushra Alsaqaf ICRC Yemen teams (rehab & comm) Cliona O’Sullivan.