Disability Reduction and Medical Rehabilitation Strategy

Current situation
After rescue and initial medical attention,[1] a sea of disabled lie literally littered in hospitals and makeshift hospitals. One generation has died, while the other will be disabled posing long term problems to the society if something is not done now.

Disability reduction and rehabilitation has at best been limited to surgical attention to the patients. No one so far has considered the short and longer term effects of physical and mental trauma to the victims.

Number of injured and our findings

• The number of injured from the earthquake disaster are more than 100,000, according to conservative estimates. The Government confirmed a figure of 60,000 injured on 17 Oct 05.

• To verify findings and to gain an insight into the extent of the problem, SN conducted a survey (on 16 Oct 05) in one of the key hospitals (Holy Family Rawalpindi) which shows that patients requiring rehabilitation are in quite a significant number.

• The hospital data from Holy Family Hospital (one of the major hospitals in the region) out of 431 trauma patients, 58% have reported serious trauma to the pelvis and lower limbs.[2] It can be safely estimated that the number of people disabled as a result of trauma will be at least 50,000 people.

• The data shows the type of injuries indicating the needs of the disabled in the disaster. The results also correspond to the findings of the Shifa International hospital that had admitted about 100 patients till then.
    

  Type of Injuries	No.	Percent Proportion
  Lower limb injuries/trauma/fractures	220	51%
  Upper limb injuries/trauma/fractures	78	18%
  Trauma needing Neurosurgical advice and/or intervention	66	15%
  Trauma and fracture Pelvis	30	7%
  Combined trauma: limbs/chest/abdomen	17	4%
  Trauma Chest and/or Abdomen	13	3%
  Amputation Lower Limb/s	4	1%
  Amputation Upper Limb/s	3	1%
  Total	431	100%

• Patients with serious pelvis and lower limb trauma. We have at least 50,000 with such trauma alone. These survivors will require at least physical therapy for: mobilization; avoiding post-op complications; and making them functional. Additionally, they will require equipment such as crutches, wheel chairs, walkers, commode chairs, etc. If these injuries are complicated with neurological problems, then they will need long term support.

• Considering the already present disabled, an estimate places more than 3 million physically disabled already residing in the province of Punjab alone, while more than 600,000 disabled are situated in NWFP.[3] Islamabad gets the brunt of patients from both the provinces because of its central location.

  Available Facilities

• There are currently only 2 good centers in Lahore and a few centers in Karachi catering to the needs of the disabled, but these are already overburdened. In the North, the National Institute of Handicapped (NIHD) and the POIPOS center (formerly PETCOAT) is there, but these too are overloaded and do not have the capacity to handle the current load of patients, let alone the patients of this calamity.

• The NIHD, which is the biggest and most equipped center in Islamabad is overloaded and has closed its OPD operations.

Strategy for reducing disabilities and rehabilitating the survivors

SN plans to build a fully equipped state of the art Rehabilitation Center for trauma victims, not only for providing physical but also psychological support. Along with it an outreach program on urgent basis is being started.

Outreach program

SN plans an outreach program as the first measure to start physical and psychological support to adults and children in hospitals.

Center for rehab medicine

• Ideally the center should be located near the affected areas. The biggest constraint, however, is the serious dearth of expertise in this area of medicine. Moving away from a major city will only add to this problem. While the patients in Islamabad may move back to their villages, a major outflux is improbable since the affected area is totally destroyed. Reconstruction will take considerable time, as the rubble needs to be cleared first, while the difficult terrain adds to the problem of reconstruction and clearing up. Furthermore, experts opine that people will search for rehabilitation centers and will themselves make efforts to bring these patients for treatment. This can be safely assumed for orthopedic patients and patients with mild to moderate neurologic deficiency.

• This is a long term Project keeping in mind that the affected might need treatment for 2-5 years. The center will continue working beyond this period and will serve other patients as well, depending on the capacity, patient load, funding and expansion potential.

• The Rehab needs can be broadly classified into:

Phases of building the Center

• The Center for Rehabilitative Medicine is a long term facility not only aiming to provide state of the art care, but also to build capacity and encourage research for promoting this area of medicine in the country. There will be 3 phases of the Project:

  - Phase 1: In the first phase, the Center will specifically focus on the needs of the physically handicapped as a result of the quake. Occupational and vocational needs to whatever extent should also be targeted as human needs cannot be segregated out into segments. The first priority, however, will be making the affected functional for survival followed with occupational and vocational training. The Center will also continue to provide services to other people as per their need and the way the situation unfolds in the coming days, weeks and months. The Center will also be adaptive in terms of meeting these needs.

  - Phase 2: A teaching and research facility will be added to the Center to train and build capacity. This self help approach will help both in the long term functioning of the Center and as a center point of research activities in this sector. Teaching and research are also dire needs of the country as reliable data about disabilities and their reduction is still in its infancy. Teaching will commence with the setting up of the center to build capacity, while a fill fledge teaching and research unit recognized by an authority and offering degree or diploma programs will be at a later stage.

  Requirements

• Space requirements: Ideally a 40x40’ hall is required for setting up the gym and basic Physical Therapy support unit. Psychological unit, teaching and research, and administrative offices will require a minimum of 4 other rooms.

Beneficiaries, CBA

• The number of people or sessions that the Center will serve according to conservative estimates is at least 500 per day. The numbers affected are far more, and therefore the cost per patient, or the number of beneficiaries can be augmented depending on the funds available.

• Pakistan’s need is not just any center, the concept of modern rehabilitative medicine has to be introduced at a larger scale, if the society has to go beyond the traditional concept of seeing disabled as ‘invalids.’

• Another point that needs special mention is that facilities need to work on modern lines to assess and meet the requirements. The disproportionate facility to needs ratio can be inferred from a single fact – most facilities are for the deaf, while they are least in number!

• The CBA is very simple. If any person is disabled, the cost to the society whether borne by the state or the society as a ‘social externality’ is far greater than rehabilitating them. This is specially true for uncomplicated ‘orthopedic trauma.’ If only any facility could ‘teach a man to fish’ for his survival, it will be a good enough job to minimize if not eliminate this social cost, especially in the longer run.

• A patient with trauma to limbs can be rehabilitated at least to a functional level where he/she can manage himself/herself, while even earn a living if we spend resources worth Rs. 25 to 30,000. This is a meager amount when considering life long disability.

Who are we?
SN is a registered charity with the Securities and Exchange Commission of Pakistan under the Section 42 of the Company’s Ordinance 1984.

What did we do so far?

Direct Disability Reduction Strategy
As a first step in dealing with earthquake victims, SN has been coordinating treatment in and between different hospitals; providing surgical/orthopedic/anesthesia/medical equipment and supplies.

The need for rehabilitation of victims is being increasingly realized as the quake has left thousands disabled.

[1] All major hospitals started elective surgery on Sunday 16 Oct 05. These include patients having orthopedic and combined orthopedic and neurologic trauma.
[2] Experts opine that survivors of pelvis and lower limbs are more in number since most receiving trauma above the pelvis did not survive.
[3] National Plan of Action: Ministry of Social Welfare Pakistan and the World Bank. Arjumand And Associates. 2005.