Missed Opportunities: The Need for Landmine Survivor Rehabilitation in Rural Areas
by Stephen Meyers, Director of International Programs, Polus Center
Persons with disabilities in developing countries are "regarded by their own communities as the most disadvantaged,"1 yet poverty alleviation and international aid programs have consistently failed to prioritize their rehabilitation and integration into society. Within the scope of mine action (landmine removal, victim assistance and mine risk education), landmine survivor assistance receives only five percent of all humanitarian mine action funding.2 Persons with disabilities, whether their disabilities were caused by war, agricultural or industrial accidents, diabetes, infection or other causes, are often ignored.
The legacy of landmines in Central America, potentially dangerous
farming activities and severe poverty have combined with the lack of
sufficient health services to disproportionately increase the
prevalence of disabilities in rural areas and force many individuals
and families to leave once-productive farms and other
income-generating activities to seek new activities in the city.
Oftentimes, the development community in general and rehabilitation
projects specifically reinforce the spatial mismatch between persons
with disabilities in rural areas and the availability of urban-based
services and programs, giving persons with disabilities the choice of
remaining isolated in their home communities or moving to the city and
having to rebuild there without family and friends.
Who are the People?
To address the needs of persons with disabilities in rural areas, a better understanding of their needs and resources is necessary. Non-directive interviews are essential not only in collecting information, but in mobilizing communities and identifying local leadership. The following is an example of the life story of a landmine survivor living in northwest Nicaragua.
Profile of Jose de la Cruez Mertinel
Mr. de la Cruez Mertinel, who volunteered to be interviewed in February 2004, is 36 years old. In 1988, he stepped on a landmine as a young soldier and has used a prosthesis since. He is from Comarca village in los lomas (the hills) and lives on his family's small plot of land.
Mr. de la Cruez Mertinel supports his wife and four children (ages 6 through 14 years old) through subsistence farming and a 500 cordoba a month ($32 U.S.) veteran's pension. Their house is handmade from palm leaves. He feels that non-governmental organizations (NGOs) discriminate against him because of his prosthesis even though he is capable of farming. His disability does not impede him in any major way with the exception of footing and balance when working with large animals. He has never heard of the Organization of American States (OAS)—a major supporter of landmine survivors—and has never been invited to be a part of any economic cooperative or training opportunity.3
There are many themes represented in Mr. de la Cruez Mertinel's story and those of other landmine survivors that agreed to be interviewed. The themes include increased risk in rural areas, lack of opportunities in rural areas, and non-inclusion in development projects and opportunities.
Increased Risk in Rural Areas
Farming is one of the most dangerous occupations worldwide. In a developed country such as the United States, over 13 million rural Americans have chronic or permanent disabilities.4 The United Nations reported in the 1990 Disability Statistics Compendium that the rate of disabilities is greater in rural areas almost universally throughout the developing world, and independent studies have found that "disabled people resident in rural areas, particularly low-/middle-income countries, have much more limited access to appropriate support resources than in urban ones."5 Inadequate educational outreach on safety issues, low access to health care and the remnants of conflict—war wounds, landmines and unexploded ordnance—have made Central American agricultural workers and their families disproportionately at risk of becoming disabled and losing their livelihoods in comparison to residents in urban areas. In mine-affected countries in Central America, nearly 95 percent of incidents of limb loss to landmines occur in rural areas.6 At Walking Unidos, a Polus Center (a U.S.-based NGO specializing in rehabilitation program planning and design)-supported prosthetic outreach clinic located in Leon, Nicaragua, over 65 percent of patients are from rural areas, despite the clinic's location within the heart of a major city and the lack of adequate transportation to the city.
According to the World Health Organization, 36,000 Nicaraguans are suffering from mobility disabilities (a significant number of whom have experienced limb loss) with approximately 20,700 people with disabilities living in rural Nicaragua.
The Rural-Urban Divide
The gap between investments in the rural and urban—or agricultural and industrial—sectors in Latin America has been well-documented since Michael Lipton first advanced his "urban bias" thesis in his 1976 book Why Poor People Stay Poor: A Study of Urban Bias in World Development. Lipton wrote that "the rural sector contains most of the poverty, and most of the low-cost sources of potential advance; but the urban sector contains most of the articulateness, organization and power...[making] the development process needlessly slow and unfair."7 Urban bias has been replicated in rehabilitation. Resources that benefit persons with disabilities are almost solely based in urban areas.
Agriculture remains a vital contributor to the economy of Nicaragua. In Nicaragua, agriculture is more important than industry in terms of percentage of gross national product (GNP) at 34.1 percent in 19988 and grew at an average annual rate of 5.4 percent during the 1990s, far ahead of both the industrial (4.1 percent) and service (1.1 percent) sector growth rates,9 despite receiving relatively low amounts of investment. Nearly half of the labor force (46.5 percent) in Nicaragua is directly dependent upon agricultural work, yet economic integration schemes for persons with disabilities have focused almost exclusively on small industry (crafts) and services.10
Researchers interested in urban bias have shown that income inequalities within countries, often resulting from the failure to invest in agriculture, basic education and other benefits that would target the poor, are a constraint upon growth for the national economy as a whole.11
There are good reasons why rehabilitation centers are located in cities—namely electricity, access to shipping, access to population of those in need of rehabilitation and so forth—and there are good reasons for fostering economic opportunities for those with disabilities living in the cities. But there should not be an expectation that persons with disabilities automatically relocate into cities. Instead, creating equity between investments in rural and urban rehabilitation must be at the forefront of new initiatives and research.
Non-inclusion in Opportunities
Whether disabilities occur as a result of landmines, accidents or illness, agricultural workers and others in rural areas are plunged into a vicious cycle of poverty. As found through interviews of persons with disabilities in rural areas and site visits to agricultural development projects in northwest Nicaragua conducted in February 2004, persons with disabilities are often excluded from potentially beneficial development projects within their communities. In the most extensive rural development project in Leon province, a 772-person cooperative with a complex in Characeca village including a dairy processing plant, fish hatchery, and poultry and livestock production, not a single person with a disability was included12 despite a prosthesis-user living on adjacent property. The Nicaraguan government and the majority of international donors have developed disability policies mandating the inclusion of persons with disabilities into development projects, yet the policies often go unimplemented.13
What Needs to be Done?
The research provided in this paper is not adequate or appropriate for drawing up specific strategies and projects in Nicaragua, much less anywhere else in the world. Such activities require participatory planning techniques that reveal more than statistics or a handful of interviews will and can mobilize landmine survivors and others to implement the projects themselves with the resources and support of partners. That said, it is still possible to offer some broad recommendations or "things to think about." Initial thoughts should include: promoting social change by bringing new groups of people together, understanding rehabilitation within an overarching framework of poverty-alleviation and increasing access to existing opportunities in rural areas.
Social Change and Leadership Through New Networks
Nicaragua passed Law 202 on the "Prevention, Rehabilitation and Equality of Opportunity for Persons with Disabilities" in 1998. However, a United States Agency for International Development (USAID) report concluded that it has not been implemented in any substantial form and its actual implementation will be dependent upon the political leadership skills of the disabled community itself.14 A central feature of Law 202 is that it mandates all medium and large businesses to follow an affirmative action policy of hiring two percent of their total employees from the disabled community.
Promoting new "person-to-person" contact, or simply bringing people together, is a move towards enacting social change.15 Such interactions, especially when centered around activities that address the common good of a given community, can foster new analytical frameworks, priorities and values for participants. Nicaragua has a strong civil society with dozens of veterans organizations, self-help associations and other disability-focused grassroots activities. Unfortunately, many are based in cities and lack the resources to organize in rural areas. There may even be attempts to organize in rural areas; unfortunately, from the small sampling made, it is obvious more needs to be done. Bringing representatives from these groups out to the rural areas to pass on their ideas, establish new contacts and foster rural chapters is essential. Rural areas are not a wasteland of civil society. Existing cooperatives, non-governmental associations, church groups, schools and so forth are already available. Bringing community leadership together with persons with disabilities and encouraging their inclusion in the community is a necessity for social change.
Disabilities and Poverty Alleviation
The full social and economic rehabilitation of persons with disabilities has been identified as an effective strategy for poverty reduction16 for whole communities, yet disability continues to be a low priority in national and international development plans. The World Bank's Voices of the Poor study identified persons with disabilities as often considered "the most disadvantaged by their peer groups," or, put simply: the poorest of the poor. It is estimated that 25 percent of people in developing countries are adversely affected by disabilities, especially because of the loss of financial resources, employment and added dependence of themselves or a family member,17 and the entire nation is affected by the loss of tax revenues, increased use of resources from social safety nets, and the cyclical effects of creating a permanent underclass. Disability and poverty are related and cannot be solved without addressing both because "not only does disability feed poverty, but poverty—which contributes to increasingly hazardous environments while limiting access to health and medical services—is for many also the cause of disability" and "contributes to making the disabled population poorer and keeping them beyond the possibilities to pay for services they may need."18
The International Labor Organization's Disability and Poverty Reduction Strategies 2002 analysis of the International Monetary Fund (IMF) and World Bank's new Poverty Reduction Strategy, an attempt to reduce poverty through a bottom-up approach replacing Structural Adjustment Programs concluded "persons with disabilities have not been involved in an opportunity to be included in the most important poverty-reduction initiative of recent years."19
The rehabilitation and disability advocacy community needs to not simply focus on "disability" projects, but to work with USAID missions and others to include persons with disabilities in other priority areas. For example, in a recent meeting with a USAID mission in Ethiopia, it was learned that no provisions to include persons with disabilities in a national HIV/AIDS initiative had been made despite the fact that people with disabilities, especially women, are disproportionately affected by HIV/AIDS. The Polus representatives were able to advocate that an association for women with disabilities be included among those chosen to implement the project. It will most likely take further advocacy for such inclusion to take place, but it is an absolute necessity.
Rehabilitation workers have a responsibility to learn about the full spectrum of poverty-alleviation activities in an area, advocate for the inclusion of persons with disabilities, foster partnerships between rehabilitation and non-disability development groups, and educate other aid workers on disabilities and their common needs with the entire population.
Access to Opportunities
Many local Leon organizations have formed cooperatives to address the near-100 percent unemployment of persons with disabilities by providing job training and employment to persons with disabilities, but few have been sustainable or successful as a gateway to other opportunities. An Inter-American Development Bank study released in 1997 found that many "specialized education and social programs perpetuate segregation and dependence of people with disabilities, and yield little or no return to society and are costly to be sustained."20 In the past six years, the few employment projects that do provide opportunities to persons with disabilities have continued to exclusively target persons with disabilities, thus replicating social attitudes that see persons with disabilities as different, the objects of charity and not socially valued. These activities have included income generation but also have not provided the opportunity for persons with disabilities to pursue jobs outside these designated, low-paying areas21 and prevent individuals from exercising choice and building upon their skills, interests and resources.
Many persons with disabilities in rural areas have land, skills and the desire to continue farming. Focus must be placed upon finding creative and appropriate ways to increase production from farmers, ranging from advocating that persons with disabilities be included in rural cooperatives and micro-credit schemes, using assistive technologies, and increasing access to spaces and resources. Short-term solutions such as a piñata-making workshop or sending individuals to the city to sell lotto tickets fail to provide long-term solutions that are so crucial to agriculture in rural areas. Assistive technologies, such as those developed by Breaking New Ground at Purdue University already exist and can be adapted to needs in Central America. Expertise in universal design is growing in the developing world and must be utilized at every opportunity. Public awareness grows when persons with disabilities assume leadership and other valued roles.
Beginning at the grassroots level, persons with disabilities must be given the opportunity to identify their own access priorities and demonstration projects, and those priorities must be addressed. The knowledge learned must be used to then create a blueprint for public policy and further implementation.
Returning to Jose de la Cruez Mertinel, introduced earlier in this article, it is obvious that he and his family are extremely vulnerable. That said, he also has resources and talents that could benefit his five dependants and his whole community. To take on the challenge of truly providing new social and economic opportunities and rehabilitation for persons with disabilities in rural areas, extensive planning, advocacy, learning and the implementation of pilot projects will be required. The time to start is now.
*All photos courtesy of the author.