Mohammad Rasool is base coordinator for Humanity & Inclusion in Afghanistan, managing our work in the Kandahar and Nimroz provinces. There, our teams are providing rehabilitation and psychosocial support. In this interview, Mohammad describes the situation on the ground.

Q: What is it like living in Afghanistan at the moment?

People are still struggling with poverty, displacement, drought, the risk from Improvised Explosive Devices (IEDs) and threat from ISIS. Additionally the country is facing a failing health system and the economy is also on the edge of collapse. So people are highly distressed as they don't know what will happen next in this highly unpredictable situation.

Daily, thousands of people are aiming to leave the country due to protection issues or to seek a better life out of the country. Everywhere in Afghanistan, there is food insecurity and there's a huge need for humanitarian assistance.

Q: What is the level of need for rehabilitation services in Afghanistan?

Even though the conflict is now over, I mean the big conflict between the previous government and the IEA, the battlefields and the districts are still highly contaminated with explosive remnants of war and IEDs. So, of course, the need for physical rehabilitation and risk education, and also for psychosocial support, remains high.

Q: Could you describe how Humanity & Inclusion's teams are supporting people in Afghanistan?

We have several approaches to reach people in need of services, especially rehabilitation, psychosocial support or skill development (which is for income-generating activities).

For instance, we provide support in the rehabilitation center where people are referred to us by other stakeholders including humanitarian partners. And we also have mobile teams. We go to the communities where we deliver the services directly to people. We also refer them for follow-up services to other partners and also to the rehabilitation center if they need further support.

Q: What is the level of injuries at the moment in Afghanistan?

In Kandahar, approximately one-fourth of the people we are seeing in our rehabilitation center are survivors of the conflict. Either they have acquired their injury in the recent conflict in the recent months, or they are the victims of the conflict in the previous years, but they didn't have the opportunity to access the center. We also see people who have injuries from road accidents as well as people who acquired a disability during birth.

Q: Are you able to share the story of a patient that particularly affected you?

I will share one of the story out of a thousand because in our center we are seeing 9,000 patients every year.

One of the people who was referred to us in the recent months was Anisa, an 8-year old girl from Zabul Province (pictured above). A mortar bomb hit her house while she was playing at home with her cousins. She was badly injured and she was taken to several hospitals to treat her.

Unfortunately, her left leg had to be amputated and then she was referred to the rehabilitation center in Kandahar, which is managed by Humanity & Inclusion. Our team at the rehabilitation center worked with her for several weeks to help her recover. She was happy that she could play again with her cousins or go to school.

Q: What are the major challenges you face at the moment?

Certainly, there have been some changes as the new government is not well established yet and the public service remain interrupted. So there are a lot of uncertainties and the new government is trying to introduce new guidelines procedures. Female staff who are working for the public sector, apart from the health sector, are still not able to attend work. We had some challenges related to access for our female staff to our community-based activities. We had a lot of interaction and intensive engagement with new authorities. Finally, we succeeded and access for our female staff was granted.

Q: What do you enjoy the most about your job?

I like visiting my team while they are delivering services to the people we support. I take the opportunity to directly hear from my team and their patients, listening to their feedback, suggestions and challenges that they face in the day to day activities.

Q: Do you have any message for our supporters here in the U.S.?

Of course, I have a message: The people of Afghanistan really need the support from the international community now more than ever. So please, please don't forget Afghanistan in this difficult time.

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When creating artificial limbs and braces, Humanity & Inclusion uses alternative, innovative solutions to limit negative environmental impacts.

Artificial limbs and braces can be life changing for many people. They open the door to countless opportunities and contribute to the invaluable autonomy and independence of their users. However, making these devices often requires an incredible amount of energy and materials.

“To make an orthopedic device, we need a lot of plastic, metals, water, plaster, carbon, resin, and more,” says Abder Banoune, rehabilitation specialist for Humanity & Inclusion.

“It takes a lot of energy, and a lot of people to make one simple device,” Banoune continues. “Each one is custom-made for the user, and new ones must be made as people grow or their bodies change. For example, many adults change prosthetics every five years, but amputation is for life. So you can imagine how many devices one person would have in their closet after 40 or 60 years. Children need to change even more frequently (every six months or a year) since they grow more. This results in a lot of waste.”

Humanity & Inclusion is committed to making quality rehabilitation care accessible to people all around the world, while remaining conscious of its ecological impact. Low-income countries, where Humanity & Inclusion primarily operates, are disproportionately affected by the negative consequences of waste, climate change and environmental neglect, all of which magnify humanitarian needs. As part of Humanity & Inclusion’s commitment to the communities it serves and to their environments, the organization takes a three-prong approach to limit waste and energy use in creating assistive devices: reuse, reduce, recycle.

Reuse

After seeing old assistive devices going to waste, Humanity & Inclusion’s Rehabilitation Director Isabelle Urseau had the idea to reuse second-hand artificial limbs and braces. Banoune has seen the same thing.

“When I was working in Africa, the centers all had huge piles and containers full of destroyed or rusted devices that could not be re-used,” Banoune explains. “They are just dumped in the backyard where they would stay forever.”

In Lyon, France, Humanity & Inclusion operates a second-hand prosthetics workshop called “La Poudrette.” It’s run by retired prosthetics and orthotics professionals. The workshop receives used devices and dismantles them, conserving all of the re-usable components that can help construct new devices.

“About 50-60% of the device can be re-used,” Banoune explains. “Sometimes, if you need to repair a device, you only need one part. Instead of buying new components or having to make an entirely new prosthetic, we can still use the parts that are good quality from the old ones.”  

La Poudrette has grown significantly since its creation and is now dismantling as many as 1,500 prosthetics each year, with plans to double or triple their actions in the near future.

Reduce

In 2016, Humanity & Inclusion became the first NGO to use 3D printing to make braces in low-resource settings. In Uganda, the organization uses the innovative technology in refugee camps to scan individuals in need of orthopedic devices, and send the digital files off to be 3D printed in a separate location, without the recipient needing to travel to a rehabilitation center. By doing so, Humanity & Inclusion can reach more people in isolated areas while using less energy and fewer materials than the traditional method of making these devices.

When making devices the traditional way, a cast of the body is first made out of plaster, which is difficult to recycle. Plastic is then heated to 392 degrees Fahrenheit to be shaped onto the plaster cast, before later adding components such as metal joints, foam, resin laminate and others. The process requires thousands of gallons of fuel, a powerful generator, and a large center to house the equipment.

“3D printing is a unique approach to making orthopedic devices without needing huge equipment, lots of energy, or a lot of materials,” Banoune says. “It’s all virtual, so instead of using plaster, we can just scan the limbs. We don’t need a huge space and the printer only uses a small amount of energy—about three or four times less than the traditional method. In the future, I think we can power them by solar panels, which would not be possible traditionally. It’s ecological, and it is inexpensive.” 

Recycle

Though 3D printing is emerging as a possible solution, plaster-based creation is still the norm for most devices. The plaster required to make artificial limbs and braces is often shipped internationally and can only be used once before being thrown in the trash. Gypsum, from which plaster is made, makes up 400,000 tons of waste worldwide. Humanity & Inclusion alone creates 5 to 10 tons of gypsum waste per year through prosthetic creation, and is determined to find a solution.

Humanity & Inclusion has partnered with the National Institute of Applied Sciences, an engineering school in France, to conduct research to solve this problem. A program at the institute is performing experiments and studying efficient ways to re-use and recycle the plaster needed for the prosthetics process.

Another research program is looking at ways to locally source and recycle materials such as plastic bottles or vegetable fibers to create the filament used in 3D printing.

“It’s important to find adapted, local solutions,” explains Magdalena Szynkowska, Humanity & Inclusion’s Innovation Development Officer. “Every context might have different materials available, different vegetable fibers, and variety of types of plastic used in plastic bottles, so there may not be one single answer. It is complicated work, but I am confident that we will find solutions.”

GREEN Initiative: Humanity & Inclusion is committed to reducing the adverse effects of climate change on populations worldwide. We help communities prepare for and adapt to climate shocks and stresses, and we respond to crises magnified by environmental factors. Applying a disability, gender and age (DGA) inclusion lens across all our actions, we advocate for practitioners and policy-makers to embed DGA in their climate work as well. Humanity & Inclusion is also determined to reduce its own ecological footprint by adapting and implementing environmentally conscious approaches to humanitarian action.

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Four months after a 7.2-magnitude earthquake struck Haiti, Humanity & Inclusion's emergency response continues with the distribution of hygiene kits to people with disabilities.

At least 144 people were killed after a fuel tanker exploded in Freetown, the capital of Sierra Leone, on Nov. 5. After assessing needs in the field, Humanity & Inclusion is moving on to the next stage of its response: assisting victims.

Humanity & Inclusion teams were working in Freetown when the explosion occurred and immediately began evaluating needs in the community. The victims include especially at-risk groups such as children, aging people and people with chronic diseases.

Focusing on rehabilitation and psychosocial support, Humanity & Inclusion will work in partnership with other organizations and the Freetown city authorities over the coming days to provide support to:

• 200 injured survivors of the explosion
• Relatives of the 144 people who have died
• 1,172 indirectly affected members of the community
• 50 health professionals

Rehabilitation and psychosocial support

In addition to emergency medical care, victims of the explosion will need long-term rehabilitation and psychosocial support.

Hundreds of people were injured in the explosion, many with severe burns. Burn victims risk developing joint contractures and difficulties with movement, and require special rehabilitation care. Unfortunately, physical therapists in Sierra Leone do not have expertise in caring for serious burn victims. Humanity & Inclusion plans to develop targeted rehabilitation activities so patients can get the care they need.

When people experience a traumatic event on this scale, victims and their families need help to overcome their pain and the impact of the accident.

“We plan to assist victims affected directly and indirectly by the disaster,” says Pauline Ducos, Humanity & Inclusion’s director in Sierra Leone. “Psychosocial support and rehabilitation care are among our main priorities. Humanity & Inclusion will help victims overcome the disaster and build their resilience. Social workers from our partner organization will reach out to each victim and their family, listen to them and refer them to specialized services, if necessary.”

Humanity & Inclusion’s emergency response includes:

• Rehabilitation care for burn victims: physical therapy sessions; patient follow-up; covering transportation costs
• Psychosocial activities: individual and group support; paying wages of psychosocial staff members
• Training health staff

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Humanity & Inclusion’s Telerehabilitation Project Manager, Martin Jacobs, answers common questions about a new telerehabilitation software developed by the organization and being launched in Vietnam.

Q: What inspired Humanity & Inclusion to develop OpenTeleRehab?

OpenTeleRehab was inspired by the need to improve access to rehabilitation services in communities and strengthen discharge procedures. Many people have the mindset that there are rehabilitation professionals just around the corner at any given time, and that these services are easy to access. We need to realize that the context is different in different countries. People often need to travel to receive care. It’s costly for them to spend the money to travel, to pay for their consultation, and they miss out on earning income while they’re away from work.

The software aims to avoid multiple trips back and forth, increase our capacity to provide services over a distance, and increase the ability to follow-up with patients. We have seen how useful telerehabilitation can be in situations like the Covid-19 pandemic, where physical services are closed, or in emergency settings where rehabilitation needs surge and hospitals must quickly discharge patients without a way to follow-up afterward. With OpenTeleRehab, access can be improved because it reduces some of the current barriers to rehabilitation services.

Q: How is telerehabilitation software different from simply watching online videos or using internet resources?

It is important to rely on the expertise of rehabilitation professionals, who are trained to design individual treatment plans for optimal functioning. This helps prevent the possibility of further damage, which could be caused by following inappropriate practices or advice we may find online. Following a treatment plan remotely does not mean you are on your own. With OpenTeleRehab, even while you are remote, you are getting individualized care that is designed and adapted for you by a professional. Plus, users receive regular follow-up from their providers. Humanity & Inclusion’s approach is not only to facilitate service delivery, but to provide quality services. Our ‘Do No Harm’ mandate would not be fully respected if we allowed people to self-provide rehabilitation services.

Q: How will people use the software?

In upper-low and middle-income countries, actually a large portion of the population has access to smartphones. For example, I was surprised to see how many people in rural parts of Vietnam actually have smartphones and how common internet connection is. In some countries, this may be less true, but we can rely on hybrid approaches where we have tablets in local health community centers or schools, for example. This means people will not need to have a device at home, and rehabilitation professionals will not have to travel all the way to the community.

OpenTeleRehab is specifically designed to use very little data and allow access to content even when offline, so it is ideal for low-connectivity settings or contexts where internet may come and go. Reports show that internet access is increasing every year, so it will become even more relevant for more regions over time. 

Q: What inclusive considerations were taken in designing the software?

OpenTeleRehab is patient-centered and has been designed for a wide range of users. The patient mobile app is really simple to use. Users will land on a homepage and it will immediately tell them what to do. There is also a child-friendly version, made specifically for younger users. We followed web content accessibility guidelines to ensure that the software is accessible to users of differing abilities, and we selected what we believed were the most relevant accessibility features for users. One of these is the ability to read the exercises aloud, for users with low vision.

We have also designed OpenTeleRehab to be culturally appropriate. After monitoring other software in various countries, we found that the illustrations were rarely appropriate or representative of the users. Our illustrations are gender-balanced, mostly age-neutral (with the exception of infants), and wearing loose-fitted, full coverage clothing.

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Humanity & Inclusion has launched OpenTeleRehab, a new innovative software specifically designed by its experts to provide quality rehabilitation services for isolated populations. The software opens first in Vietnam, with plans to expand to other countries.

In Vietnam, more than 64% of the population live in rural areas, significantly limiting access to rehabilitation care. This is particularly true for people with disabilities for whom traveling long distances can be challenging. There are fewer than one physical therapist per 10,000 people in Vietnam, and only 2% of Vietnamese children receive rehabilitation care when needed.

By contrast, 80% of the population uses a smartphone and 4G coverage is at 95%. Even families with low incomes typically have access to a mobile device. With its background in innovative humanitarian response and rehabilitation expertise, Humanity & Inclusion designed the OpenTeleRehab software as an adaptive solution to ensure both access to and quality of care for patients who need rehabilitation.

The software with developed in partnership with hospitals in Vietnam and JAMK University. Its development was funded by USAID and the Botnar Foundation.

Custom care, accessible to all

“The application will provide remote rehabilitation services, increasing access to care in contexts where the rehabilitation workforce is limited,” says Martin Jacobs, Humanity & Inclusion rehabilitation technical advisor and OpenTeleRehab project manager. “Patients are taught in service by their therapist how to use the patient mobile application, then, once they are home, they can access their custom treatment plan by smartphone. The treatment plan can include exercises, information, educational material and questionnaires. Therapists can organize regular follow-up audio or video calls and track patient progress and adherence to the plan.” Read a full Q&A with Jacobs about this software launch.

OpenTeleRehab aims to increase access to rehabilitation services by strengthening hospital discharge, transition of care and community-based follow-up. It should help prevent repeat hospital stays for people with long-term needs, lower patient costs, optimize functioning and reduce obstacles for individuals with disabilities in central Vietnam. Its offline features ensure that it can easily be used in contexts with limited internet access, and a child-friendly version of the patient mobile app increases engagement among young users.

Implementation and next steps

The initial OpenTeleRehab launch will be piloted in two provinces of Vietnam, serving 550 direct patients and their families. Tablets will be distributed to families if they are unable to access a mobile device. After its initial release, Humanity & Inclusion plans to further develop its services and eventually expand its use.

“The next steps will be to increase the number of exercises in the library, and to translate it to different languages,” Jacobs explains. “We will then be able to deploy the software in different countries and different contexts.”

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More than 100 people were killed when a fuel tanker hit a large truck and exploded on Nov. 5 in Freetown’s Wellington district. Humanity & Inclusion staff in Sierra Leone are working to assist the community.

Humanity & Inclusion teams responded to the affected area, checking on people injured in the explosion, and their needs. Many people will require medical and rehabilitation care.

“It’s important to treat the injured, particularly serious burns victims, by providing them with rehabilitation care,” says Pauline Ducos, Humanity & Inclusion’s director in Sierra Leone. “If casualties are not treated after they leave the hospital, they risk losing their functional abilities and may develop a disability.”

Humanity & Inclusion’s teams also plan to help survivors and their relatives with psychosocial support.

“Our current priority is to give casualties psychosocial assistance in order to prevent extensive psychological damage,” explains Mamoud Kargbo, Humanity & Inclusion’s operations manager in Freetown.

Read the latest on Humanity & Inclusion's response.

A ‘national disaster’

Declared a “national disaster” by the Vice President of Sierra Leone, the explosion occurred when a fuel tanker collided with a large truck carrying granite. Most of the casualties are street vendors and motorcyclists who were attempting to recover fuel from the tanker when it exploded.

A total of 101 people died and 200 more were injured. Half of the people with injuries are unlikely to survive, according to the latest reports.

All casualties are being treated in the city’s hospitals and clinics, which have been overwhelmed by the sudden influx of patients. The facilities do not have staff with expertise on caring for serious burns victims.

Humanity & Inclusion in Sierra Leone

Humanity & Inclusion began working in Sierra Leone in 1996, when it opened a rehabilitation center in Bo, followed by three other centers. Since then, Humanity & Inclusion has worked alongside the medical community to improve the standard of rehabilitation care. Teams also promote inclusive education, protection and mental health.

Humanity & Inclusion has responded to major health emergencies in the country, including the Ebola epidemic from 2013 to 2015, the mudslide in 2017, and the ongoing Covid-19 pandemic.

Over the last 25 years, Humanity & Inclusion has served tens of thousands of individuals, including people with disabilities, children and women to alleviate poverty and improve access to essential services.

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Humanity & Inclusion’s emergency staff has been actively responding since a 7.2-magnitude earthquake hit Haiti two months ago. Teams have already provided 1,200 rehabilitation sessions to injured people and delivered more than 150 tons of humanitarian supplies.

Deliver emergency aid to Haiti

To mark World Cerebral Palsy Day on October 6, Humanity & Inclusion highlights the importance of providing care and treatment to children born with this life-long condition.

Cerebral palsy is the most common motor disorder encountered by rehabilitation teams in the countries where Humanity & Inclusion works. Assisting children with cerebral palsy is therefore a major priority for the organization.

Seventeen million people worldwide live with cerebral palsy. It is the most common cause of motor disorder in children. Globally, people with cerebral palsy are still subject to discrimination.

Cerebral palsy is a group of lifelong conditions that affect movement and coordination. It's caused by a problem with the brain that develops before, during or soon after birth. It is sometimes associated with severe cognitive and sensory difficulties. It can also make it challenging to communicate with a child, to calm them and take care of them, which sometimes leads to rejection.

However, depending on the severity, if cerebral palsy is detected early, the parents are provided with information and the child receives immediate rehabilitation care, the likelihood of further complications can be reduced. The correct treatment can quickly transform the life of both the child and their family, and increase their chances of being able to walk, go to school, work and live a fulfilling life. 

Humanity & Inclusion takes an intersectional approach to healthcare and physical and functional rehabilitation, while working as closely as possible with the family in order to provide them with the best possible care and treatment.

First step: early detection

Children born with cerebral palsy in the low- and middle-income countries where Humanity & inclusion works are often at-risk of discrimination and exclusion.

“Cerebral palsy is caused by an accident during pregnancy or during or just after birth. Symptoms depend on which part of the brain is affected, and they change over time. If a baby does not receive treatment, they will develop problems with muscle tone and will not be able to coordinate their movements. The faster it is correctly treated, the less brain damage the child will experience,” explains Uta Prehl, Humanity & Inclusion’s West Africa rehabilitation specialist.

“Unfortunately, in the countries where we work, care staff are often not trained to detect this condition early on,” Prehl continues. “Midwives need to know how to test the reflexes of newborns, for example. These tests need to be done every three months to check if the child is affected. This is why Humanity & Inclusion trains medical staff in the early detection of the cerebral palsy whenever possible. Care staff need to make a diagnosis and parents should be provided with information and guidance on visiting a health center with their baby without delay.”

Raising awareness of parents

Many families never visit a health or rehabilitation center or go when it’s too late. Sometimes parents are unable to take leave from work or to pay for transportation to health centers. Others feel ashamed and frightened their children will be seen as different. In some countries, children with cerebral palsy are hidden away or ostracized.

Humanity & Inclusion runs family education activities to raise the awareness of parents and their communities to help people learn more about cerebral palsy and the possibilities that treatment can open up for a young child. Parents also learn about the significant role they play in helping their child at health centers and in their future care.

Rehabilitation is essential

Most of a child’s early learning and brain development happens before the age of 5. Early detection of cerebral palsy is essential to providing an immediate rehabilitation response, in addition to mobility aids and other supports. These are included in the services provided to children with cerebral palsy by Humanity & Inclusion’s rehabilitation teams or its partners. Mobility aids and other supports must be personalized, and children need to learn how to use them with help from their parents.

“With our partners, we work in direct and close contact with families, often the mothers, to ensure rehabilitation care produces the right results,” Prehl explains. “We need to provide equipment or devices adapted to the child, like mobility aids, and adapted chairs and tables, which are made to measure to give the child proper posture support. 

“We make the diagnosis and decide on treatment and orthopedic fitting using the international Global Motor Function Classification Scale, which means we can work in a way adapted to each child, based on a precise evaluation. The next step—exercises to learn how to use posture and mobility aids—depends a lot on the relationship between the mother and child, and how motivated they are.”

Many people with cerebral palsy live long and fulfilling lives with support from Humanity & Inclusion and other organizations around the world. But too many people are still left behind. Humanity & Inclusion will continue its efforts to ensure young children with cerebral palsy are able to access the immediate care they need and to increase their chances of enjoying the same rights and opportunities as everyone else.

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Thanks to an innovative 3D-printing project, 5-year-old Kennedy can walk on his own and play with other children for the first time.

Displaced by fighting in South Sudan, Kennedy’s family arrived in Uganda in December 2016, when he was just 9 months old. Now, he lives with his mother and two siblings in the Arua district.

Kennedy has Cerebral Palsy. And though he can eat, drink and hear easily, he is unable to speak. He also has limited dexterity and finds it difficult to hold objects.

“My wonderful, brilliant, cheerful little boy has had from Cerebral Palsy since birth,” says his mother. “Two days after he was born, he had a high fever; I took him to hospital in South Sudan where they diagnosed him with severe malaria. The doctors treated him straightaway, but it left him with consequences that have affected his mobility and communication skills: he can’t switch sides when he is lying down and he can’t sit, kneel or stand. He couldn’t walk without a walking frame. He depends on adults to do almost everything other children take for granted, including dressing himself or going to the bathroom.”

Kennedy began physical therapy with Humanity & Inclusion’s specialists in February 2020, after meeting with community volunteers. Despite challenges, Kennedy is growing stronger with each rehabilitation session. He’s already learned to stand and move around with the support of a walker.

In November 2020, Kennedy was enrolled in Humanity & Inclusion’s 3D PETRA project—an initiative that equips people with custom, 3D-printed braces and artificial limbs. After a consultation with a technician, Kennedy was prescribed braces for his feet. The team scanned his lower limbs, then printed braces to fit him perfectly.

As Kennedy continues his physical therapy exercises, he’ll soon be able to walk on his own with his braces. His mother is extremely grateful and delighted her son can finally play with other children in their neighborhood. Next, he’ll conquer school for the first time!

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