A glance at disability at Koh Dach island part one

June 2015 was my first trip to Cambodia. From the moment I stepped through the arrivals gate at Phnom Penh airport and was greeted by the warm smile of the pick up guy Piseth Nuth I fell in love with the Kingdom of Cambodia. During my first week I was intoxicated by the city’s chaotic yet charismatic atmosphere and the spirit of the Cambodian people. 

Despite the Khmer’s turbulent history of bloodshed, poverty and political instability the Khmer have still managed to keep a smile on their faces. The happiness and compassion of the local people has resonated so deep within me that I now consider Cambodia to be my home or “phteah” in Khmer. I often tell friends and family or those willing to listen Cambodia stole my heart and when I’m away from the Kingdom of Cambodia I certainly long to be back home. 

An accomplice to stealing my heart is Koy Phallany, executive director of Khemara Organisation. During my short spells in Cambodia I have had the honour of working alongside this fantastic grassroots organisation. Khemara’s work in the local community is endless, from running free daycare centres for disadvantaged children to running AIDS/HIV prevention projects. 

On a Sunday morning Phallany met my boyfriend and I to take us to Koh Dach (Silk Island) located just a short drive away from the capital. After taking a ferry across the Mekong river Koh Dach island is a different pace of life from the capital. With dirt track roads and traditional stilt houses painted in various shades of blue with the Brahman cows munching on hay with their bells gently ringing in the breeze.

Although the island sounds idyllic many of the residents here suffer from high levels of unemployment and poverty. The purpose of our visit was to see the Khan family who were struggling to make ends meet. The mother had just given birth to a baby girl who was just four weeks old and the father who is disabled is unable to find work. 

Before the mother gave birth the parents drove 160 km everyday to pick snails to sell where they roughly earnt $2 per day to feed a family of six. However with a baby to care for their combined wage is limited. The father struggles to find work due to his disability although a decree was signed in 2010 where state-run institutions must employ one disabled person per 50 employees, while private companies are obligated to employ one disabled person per 100. However these quotas are barely filled and disabled people are often subjected to discrimination and are unable to find well - paid secure jobs. If disabled people are able to find jobs it’s often in low-paid and dangerous work. 

Phallany heard about the family through one of Khemara’s daycare centres where two of the children attend whilst their parents are at work. Hagar International kindly donates $50 per month to the family as well as rice to help the family during these desperate times.

Unfortunately stories such as these are far too common in Cambodia. Our next stop was evident of this as we were off to see a family who live five minutes around the corner. Single mother Chenda and her two children who both attend one of the daycare centres run by Khemara on the island. Her youngest child Bopha is disabled when we arrived he had just taken a tumble trying to run around with his friends and was seeking a kiss and cuddle from Mum for his grazed knee.

This courageous little boy aged four was born with a disability, when I ask his mother “What did the doctor’s diagnose him with?” she responded “I don’t know”. Unfortunately services for disabled people are still very limited and the healthcare sector are unable to provide key services such as assistive devices, medical rehabilitation, physiotherapy, education and training. Virtually all services for disabled people in Cambodia are delivered by NGO’s and with the current uncertain funding climate many charities have had to cut back resources leaving many families without access to healthcare services. 

Bopha’s fingers and toes are locked into a fist leaving him some difficulties with his day to day life. Through the Public Health programme run by Khemara in partnership with Projects Abroad Bopha is now able to walk, previously his sister and mother carried him but with encouragement from the staff he is now up and about with his friends causing mischief. The teachers also provide him with basic physiotherapy which means his fingers are still flexible which will be extremely important for the future. 

Stories such as Bopha and the Khan family are just the tip of the iceberg. As in most developing countries, accurate statistics on the number of disabled people in Cambodia are not available. Nevertheless it is estimated that Cambodia has one of the highest rates of disability in the developing world (UN ESCAP 2002). Disability and poverty are inextricably intertwined.It is estimated that 36% of the population in Cambodia live below the poverty line of US $0.40-0.63. Poverty is a significant cause of disability. It is poor people who are often victims of mine and UXOs (unexploded ordnance) as they are forced to live near mine areas and collect food or firewood. They are also unable to access basic healthcare meaning that simple infections, illnesses and injuries often result in permanent disability because they go untreated. For example, untreated childhood ear infections are a major cause of permanent hearing loss in children. 

Although there are some fantastic NGO’s supporting the local community such as Action on Disability and Development (ADD), Handicap International and Khemara (who are looking to extend their services for disabled children) a greater understanding and awareness of disability in Cambodia is needed. 

Throughout my blog I have criticised the development sector for not including disabled people within mainstream development and Cambodia is another prime example. It is critical that organisations engage with the disabled sector, that the government is supported to resume more responsibility for its disabled citizens and that disabled people are empowered. 

If we were to witness changes such as these perhaps little Bopha and the Khan family will be able to lead a life where they have access to a secure job and healthcare. I certainly think they deserve all the happiness in the world and more. 

My next blog will be about my trip to Tboung Khmum Province in Cambodia. 

If you would like to find out more about Khemara please visit their website and to donate please visit their JustGiving page.

* Names have been changed.

The Invisible problem in Development: Part 2

The World Health Organization (WHO) estimates that schizophrenia, bipolar disorder, depression, and alcohol-use disorders affect around 450 million people and account for 12 percent to 14 percent of the global burden of disease, measured in disability-adjusted life years (DALYs) (DALYs represent the total number of years lost to illness, disability, or premature death within a given population). This number doesn’t include the 47.5 million people who have dementia or those who live with social anxiety or obsessive social compulsive disorders.


Although the World Health Organisation estimates that mental and neurological disorders are the leading cause of ill health and disability globally, there is a severe lack of interest from governments and NGO’s.


One of the reasons behind this is a lack of funding in development for mental health initiatives. Due to the market-driven nature of aid, mental health isn’t appealing to donors and projects are strongly correlated to how marketable they are to the general public. Mental health charities struggle to raise money as they are not part of the three big C’s ‘cancer, cats and children’ which tug on heartstrings and consequently purse strings. With mental health it’s harder to generate empathy, mental health problems are not always obvious therefore do not always create the snapshot image for your latest fundraising event.


Social stigma surrounding mental health restricts the formation of any real social pressure to affect governments or individuals into action. A mhGap (Mental Health Gap) report lead by the WHO in 2008 states “The stigma and violations of human rights directed towards people with these disorders compounds the problem, increasing their vulnerability; accelerating and reinforcing their decline into poverty; and hindering care and rehabilitation”.


Research by Christoph Lauber in 2007 shows that comparable to Western countries, there is a widespread tendency to stigmatize and discriminate people with mental illness in Asia. But the problem of social stigma is not just an issue in Asia, Nora Mweemba, who works for the WHO in Zambia, explains that many people suffering from mental health problems don't come forward for treatment because "communities still regard mental health as a misfortune in the family or some sort of punishment [from God]". The pathway to care is often shaped by scepticism towards mental health services and the treatments offered and families tend to turn to traditional healers. There are significant cultural barriers which need to be overcome and further research by organisations to deliver effective mental health policies.


Many of the countries do not have the legal infrastructure to protect those with living disabilities. Although many countries have signed the ‘Convention on the rights of persons with disabilities’ institutions still lack funding, training and the resources to adequately care for their patients. Unfortunately this leads to human rights violations where patients are locked, chained, isolated and denied their basic human rights.


One of the other barriers to the development of mental health services has been the absence of mental health from the public health priority agenda. The report for mhGap launched by the WHO research shows that this has serious implications for financing mental health care, since governments have allocated meagre amounts for mental health within their health budgets. But with so many health concerns facing developing countries mental health is not always top of the agenda.


Although mental health problems account for almost 13% of the world’s total disease burden and costs the world some $ 2.5 trillion per year, yet the amount invested in treating mental health problems is barely a fraction of this. Less than two percent of the health spending in most low and lower-middle income countries.


Gary Belkin, Executive Deputy Commissioner, New York City Department of Health and Mental Hygiene says;

“The challenge is we have in the order of a billion people on the planet who will have a mental health problem in their lifetime and not get evidence based care for it. A response to that sort of problem needs action at a global level. It needs the sorts of global structures we’ve created for malaria and HIV to be created for mental health as well”

However the problem isn’t just a medical concern, in a recent report by the APPG (All-Party Parliamentary Group) highlights how mental health problems are a brake on development as they cause (and are caused by) poverty. This is part of a wider development concern as not addressing mental health fuels social failures including poor parenting and school failure, domestic violence,and toxic stress, preventing people with problems and their families from earning a living.


Although there have been some recent efforts to raise the profile of mental health as a development issue. In 2008 the WHO launched the Mental Health Gap programme and mental health has been included within the SDG’s in 2015 (Sustainable Development Goals) . The mhGap has praised improvements in countries such as Guinea where they are running a services to support ebola survivors and improving care across disaster - affected regions such as the Philippines.


However the response to mental health in the development sector is still severely lacking. There are very few global organisations leading the way for mental health issues. Basic Needs and International Corps are two international charities which are mental health focused and are calling for governments and aid agencies to address the issue.


In order to tackle the growing mental health crises governments and NGO’s need a collective response. Mental health should not be left to the public health or development sector - schools, hospitals, community groups, charity groups and government bodies should work together to tackle mental health at a global level.

Mental Health the invisible problem in international development

Mental Health is the shadow lurking in the corner which nobody wants to talk about in international development. The World Health Organisation estimates that mental and neurological disorders are the leading cause of ill health and disability globally, but there is a severe lack of interest from governments and NGOs.

Below are some images which highlight the state of mental health in the developing world. Due to social stigma, lack of resources and funding for mental health services people are often chained or locked up.

Mental health is not considered a disease by people in Bangladesh. These women are among the estimated 14.5 million adults in Bangladesh receiving limited mental health care.
 Sourced from  The Guardian http://tinyurl.com/qxhgthx, photography by Allison Joyce

Najeebullah has scizophenia and drug induced psychosis.After becoming violent and stabbing one of his family, he has now been chained up in a hospital in Kabul  Sourced from  The Guardian http://tinyurl.com/z5mm459, photography by Magda Rakita

Anne has been locked up for ten years without a window, according to her father she doesn't like to eat much. She used to enjoy running but now she cannot stand.
Sourced from Bored Panda http://tinyurl.com/create.php, photography by Andrea Star Reese

According to a recent study done by The Lancet 173 million Chinese people suffer from mental health problems. Only 158 million of those have never received any professional help. Sourced from  The Guardian http://tinyurl.com/ld5er82, photograph China/photos: Getty images

Due to a lack of understanding and social stigma locking people up is often common practice in Indonesia.

Sourced from Bored Panda http://tinyurl.com/create.php, photography by Andrea Star Reese

After Typhoon Haiyan in the Philippines the true nature of how people are dealt with mental health disorders was revealed. Many people were locked up and left to die after the typhoon hit in 2013. 
Sourced from  The Guardian http://tinyurl.com/ld5er82, clip taken from a video directed by Simon Rawles

The Syrian Refugee Crisis: Shining a light on the response to impairment, disease, and disability

By Ollie King

As of 2014, Syrians constitute the worlds largest refugee population. To most, this comes as no surprise. The media is packed with stories of huge migrations of people fleeing war-torn Syria in search of refuge, a journey beset with danger for even the most able-bodied men, women, and children. Those so often ignored or ill-considered in these circumstances are those who are not able-bodied - refugees suffering injury, impairment, and disability.

The recognition of persons with disabilities is a fairly recent addition to the United Nations (UN) treaty body system. The introduction of the Convention on the Rights of Persons with Disabilities (CRPD) in 2006 is the manifestation of this recognition; a unified document of special clauses and elaborations on previously established rights that serves to shine a light on the needs of people disabled by a society that is unable to cater to their needs. The CRPD is intended to mark the end of a long history of invisibility for disabled people in the eyes of nation-states and the wider international community. However, in the context of human displacement, the promise of recognition and special attention is severely lacking. Article 11 of the CRPD is explicit in committing States Parties to the protection and safety of persons with disabilities in humanitarian emergencies. So where is the international community failing in its mandate to protect refugees with disabilities? What can be done to improve the recognition and response to disabled refugees fleeing conflict?

 Picture sourced from http://www.aljazeera.com/indepth/inpictures/2015/09/window-desperate-journey-150917085100247.html

A rare example of a comprehensive study carried out in this area comes from HelpAge International and Handicap International. Published in 2014, the collaborative study collected data from Syrian refugees in Jordan and Lebanon, seeking to establish their number and their specific needs. Alarmingly, it found that 22% of refugees are affected by an impairment, with 6% affected by an impairment deemed severe (to illustrate how significant this is, the World Report on Disability estimates that 15.3% of the entire world’s population suffers from an impairment). Furthermore, elderly people are disproportionately represented - 70% have at least one impairment, and are twice as likely to suffer intellectual impairments when compared to children.

Levels of conflict-related injuries are notably high in the case of the Syrian conflict - one in 30 refugees that fled to Lebanon, and one in 15 refugees in Jordan were injured as a direct result of the fighting. Working-age men are particularly exposed to the risk of injury; aside from their role in combat, the responsibility for fetching food, water and other provisions often falls to them. Some young men even travel back to Syria to check on their property, contributing further to a life already fraught with danger for Syrian males in particular. Without effective rehabilitation, injury-related health conditions are likely to deteriorate into permanent disability.

Picture sourced from www.http://edition.cnn.com/2012/12/13/opinion/syria-unreported-refugees/

Looking to issues of psychological well-being, half of the refugees affected by impairments, injuries and non-communicable diseases reported at least one sign of recurring psychological distress. These signs include changes in behaviour, emotional state, cognition, and relationships. Once again, the elderly were disproportionately affected, with over 65% reporting one or more of the aforementioned signs.

Crucially, the study found significant difficulties in ‘activities of daily living’ (ADL). ADL is a term used by healthcare professionals to refer to basic self-care activities such as bathing, feeding and dressing oneself. In the general refugee population worldwide, 6% reported difficulties in ADL. Within the Syrian refugee populations in Lebanon and Jordan, 45% of refugees with an impairment, injury or chronic disease had difficulties in ADL; this figure rose to 60% for elderly refugees. This is a staggering increase with severe ramifications. Those struggling with ADL are far less likely to access family and community support strategies, and static and mobile outreach programmes.

As demonstrated, the danger and suffering that disabled people face during humanitarian emergencies is significantly enhanced. The inability of response programmes to tackle the needs of disabled refugees effectively comes down to the lack of a clear picture. Whilst the study conducted by HelpAge International and Handicap International is a step in the right direction, we still lack an understanding of the level and nature of help required within the majority of refugee populations around the world. For this reason governments, national institutions, and NGOs remain profoundly limited in their responses. Injuries become permanent disabilities when they are not treated and rehabilitated, chronic diseases go unchecked and untreated without simple diagnoses and medication, and psychological distress is allowed to fester and endure to become yet another plight for those already impaired.

Picture sourced from http://www.mirror.co.uk/news/world-news/syrian-refugee-carries-disabled-brother-6380968

For those nations receiving refugees, it is essential that they work with dedicated NGOs and healthcare organisations to share information and research for adequate response programmes. Data collection should be inclusive and participatory, allowing all groups an opportunity to engage in focus group discussions so that they can have some input into programme design. Sphere standards must be applied to the collection of data, which should be disaggregated by age and gender (The Sphere Project, launched in 1997, was developed to set minimum standards in the core areas of humanitarian assistance). In addition, data must be further disaggregated by impairment, injury, and chronic disease. Using questions established by the Washington Group, measurements of disability must be incorporated into every statistical survey that concerns refugees. With the collection of refugee statistics remaining constant, the information produced can be compared between different contexts. The accurate collection of data will ultimately contribute to the design and delivery of specific response programmes that are the result of a rigorous analysis of the problems at hand.

Historically, the recognition of the specific needs of people with disabilities has been severely lacking. Left in the dark, they have been overlooked in the formation of policy and the consideration for accessibility in societies worldwide. Today, the CRPD has led the way in providing visibility to people with disabilities. However, consideration for those suffering with a disability within refugee populations is far from adequate. The first step in providing services for this diverse group of suffering people is recognising their size and the diversity of their needs. While HelpAge International and Handicap International have set an important example, we are far from reaching the necessary depth of understanding. Only a deep understanding will allow for a response that is so desperately needed by the most vulnerable of an already vulnerable refugee population.

Where is Sustainable Development Goal 18?

Not far from my office in Hanoi, Vietnam is the UN Headquarters. On a daily basis I’m reminded of the Sustainable Development Goals (SDG) which were decided at the 2015 financial summit in Addis Ababa. Hanging proudly from the grey and heavily secured building hangs the colourful banner of the SDG. The seventeen friendly infographics remind the hundreds of workers whizzing by that the staff are busy typing on their computers writing inspiring development policies to end world poverty by 2030.

However when you take a close glance at the SDG’s the UN seem to have made yet another monumental blunder. They failed to include any specific goal which directly addresses the needs of disabled people. Unfortunately, this is not the first time disabled people have been left out of the development agenda, disability was not mentioned in any of the Millennium Development Goals, nor their targets or indicators.

During this round of talks the United Nations had a second try. Delegates had the chance to include disabled people in the development agenda for the next 15 years and make history. Unfortunately the UN failed to really include disabled people and their inclusion in the SDG’s felt like more of a ‘tick box’ exercise.

After reading through the SDG’s the lack of inclusion of how disability will be addressed in development was frightening. To be precise only Goal 4 (Education), 8 ( Economic Empowerment) , 10 (Reduce inequality) and 11 (Sustainable cities and communities) mentioned disabled people in the section headed ‘targets’. Empower, promote, build, upgrade and enforce are all powerful adjectives which feels uplifting and inspiring but in reality will these action words really make an impact on the ground?

It is undeniable fact that people with disabilities are consistently among the poorest in many communities.

The World Health Organisation in collaboration with the World Bank recently estimated that 15% of the world's population - some 1 billion people - live with disabilities that have a direct impact on their daily lives. That translates to one household in every four has a disabled member.

They are not only poorer in economic terms but are also comparatively poorer in many areas- access to health care, education, employment and social inclusion. Moreover, people with disabilities often face stigma and prejudice that severely limits their ability to have a voice in their households and communities.

If international institutions are able to collect and analyse data why are the needs of disabled people not being addressed? Nora Ellen Groce, Director of the Leonard Cheshire Disability and Inclusive Development Centre at University College London, addressed this issue in a talk to Oxfam last year in 2015. During this talk it was highlighted that one of the key reasons is “that many development practitioners still consider disabled people - if they consider them at all - as objects of charity or as recipients of medical care rather than an impoverished population that is an international development concern”.

Yet the single greatest problem facing people with disabilities worldwide is poverty. Like all impoverished people across the world disabled people need viable and sustainable solutions to employment. The International Labour Organisation estimates one of every 10 people in the world has a disability — some 650 million worldwide. Approximately 470 million are of working age. Their social exclusion from the workplace deprives societies of an estimated US$ 1.37 to 1.94 trillion in annual loss in GDP. An estimated 80 per cent of all people with disabilities in the world live in rural areas of developing countries and have limited or no access to services they need. Providing decent work for people with disabilities makes social as well as economic sense.

‘Leave no one behind’ which has been a key feature of all discussions focused around the post-2015 agenda and SDG goals. Although this is a catchy slogan, the development sector and leading international institutions need to work alongside governments and local communities to include disabled people in the fight against poverty.

Rather than flirting with words such as inclusion, integrity and equality the UN needs to adopt a policy which takes decisive action and offers real practical solutions for people with disabilities. Disabled people need to be more than afterthought or tickbox exercise.

Fortunately Leonard Cheshire Disability are leading the way in addressing the development gap between development and disability. In alliance with 54 countries, DPOs (Disabled people’s organisations), disability-focused NGOs and organisations throughout the development community, Leonard Cheshire Disability are trying to increase awareness and include people with disability in global development areas.

It is charities such as these which give hope that disability will become an issue which will be included in all development efforts. Twenty years ago women were routinely overlooked in international development efforts. Now few would think of designing a policy without considering gender issues, we now need a development effort which always includes disabled people. Until that time, people with disabilities will continue to be at risk of continuing to live in isolation and extreme poverty. In the meantime we all need to make a concerted effort to keep campaigning to raise awareness.

If ignored the UN run a real risk of not meeting their SDG’s by 2030. It is suggested that because of the size and depth of poverty associated with disability, many of the forthcoming Sustainable Development Goals will not be met unless the needs of disabled people are included and met. At the very least the UN and the development sector need to push forward for an inclusive agenda. Otherwise we are at real risk of locking disabled people into a cycle of poverty whilst their non-disabled peers break free.