|Common street scene—kids like this find a familiar corner to call home for the night in most undeveloped cities worldwide.|
We motor into the refugee camp near Barranquilla, Colombia, laden with $40,000 in medical and rehabilitation supplies and two local medical students who have volunteered to help.
During our six months' absence, the World Health Organization (WHO) built a school in the camp. It is typical "third world": cement, wrought iron, no carpet or air conditioning. However, it adds an aura of stability and permanence to the makeshift construction of the one-room hovels squeezed into its shadow. It is more than a building: it is a monument to the future--testimony that there are people on the outside who believe there will be a future.
The leaders of the refugee camp take us to a large, open structure that will someday serve as a lunch room--if the luxury of regular meals ever becomes a reality. The lunchroom-without-lunches is empty, except for a small class of children whose desks are bunched into a corner.
|Uninvited visitors to our clinic in the refugee camp.|
There is something new in the camp: two local policemen are stationed at the school. It was the only way a teacher would agree to work at the new building, Amelia, clinic coordinator, tells us.
One of the policemen, quite a large man, has somehow squeezed himself into one of the small desks. He is surrounded by children and scarcely notices us as he grades papers and encourages little heads with soft pats. It is obvious the children adore him.
The other guard watches everything we do with suspicion. Only after we offer his family the services of an American doctor does a smile appear.
So much for America's stereotypical perceptions of Colombia and its perpetual aura of violence. Horrors are ever-present, but they represent only a small corner of the snapshot. Colombia is full of people exactly like us, maybe even better. Perhaps the difference is revealed by a subtle form of conflict: the hearts and compassion of Colombians are just tested more often--no doubt, every day.
Sickness Plagues the Camp
|Policeman-teacher at the WHO school where our clinic is held.|
There is much sickness in the camp, we are told. Within hours of the first clinic, it is apparent there is more sickness in the camps this trip. My old nemesis, scabies, is ravaging small children and I hate the prospect of catching scabies even though I never have--yet! Can you imagine what it is like to be a small infant and have a complete body infestation of these dreadful, microscopic, itch-producing insects--endured in unrelenting heat? What a horrible way to be introduced to the human condition!
As the clinic progresses, I'm told, "You're not going to like this . . . that little girl over there is not eating. She is so malnourished; Dr. Kohler can't find enough muscle to inject Rocephin." The child also has pneumonia--a potential byproduct of cerebral palsy is chronic aspiration.
Across the room, a 15-year-old girl hasn't spoken a word since she was physically abused by her father.
Providing O&P Care
|Debbie Plescia, CPO, and a friend with a new arm.|
Debbie Plescia, CPO, is handling the orthotics and prosthetics for the team. Some patients are late because they must walk long distances. Others appear out of nowhere and hit the schedule like a bowling ball. Plescia never flinches, taking them as they come with a smile. Her only comments on the last day pertain to how overwhelming the job is. Despite this she's committed to returning as part of the solution.
Fittings are complicated by the prospect of a two- to three-month interruption in follow-up. Continuity of short-term rehabilitation scenarios and long-term objectives of the program necessitate networking among local talent. Marta Rojas of Laboratorio Ortopédico in Barranquilla volunteers her time and facility. Her two nephews accompany her as technicians. They constantly smile and jump at the opportunity to make any adjustments (which necessitate a ride across town to their laboratory) and thank us for the opportunity to help the poor.
Mr. Wulfran Palmer is fitted with a right BK prosthesis. His distal tibia protrudes two centimeters from the conjoined muscle and vascular bundle. It is a probable site of abrasion. In the US, the prosthetic evaluation would recommend an immediate revision. Not so here in Colombia. Surgery is simply not an option--yet.
Our new associates from Laboratorio Ortopédico eagerly accept Mr. Palmer as their patient, and a follow-up appointment is set.
Hanger RFD USAID Grant Concept
Hanger Rehabilitation for Development (Hanger RFD) submitted a grant concept paper to the US Agency for International Development (USAID) in May 2003. Most funding focuses on development, at least in USAID's manual. It is a good philosophy. Don't just give a person a fish; teach him how to fish, as the old saying goes.
|Typical patients present at each clinic.|
The Hanger Orthopedic Group's humanitarian or NGO (nongovernmental organization) division was founded with this in mind. The project for which the grant paper was submitted is unique in its scope. In countries like Colombia, a prosthesis or orthosis can mean the difference in a whole family's survival. Competition for resources on the street is a mean physical hustle. However, O&P rehabilitation won't be attempted in a clinical vacuum. Medical care and physical and occupational therapy are included in Hanger RFD's philosophy of O&P intervention. But the concept doesn't end there. During its 36-monthinitial funding period, 18 full medical/rehabilitation clinics are scheduled in the camps. Twenty local candidates will travel to the US for basic O&P technical training. Half will be former guerrillas or FARC combatants who have surrendered and asked to begin life again as mainstream Colombian citizens.
The US focus on aid to Colombia is developmental in nature. Unlike other US projects, funds must be directed specifically against the drug war. Humanitarian concerns appear secondary but are not omitted from the plan. Our focus has consistently been on refugees and displaced persons. It is our hope that such appropriate targeting will resonate positively among USAID's planners. At the least, they will recognize physical rehabilitation is a unique type of humanitarian aid that can serve as a fulcrum against the drug interests in Colombia.
|Dr. Kohler and one of her regulars.|
During our early trips, we learned that the Colombian government does make funds available for the disabled and ill, but these rarely reach the poor. This is due to pervasive corruption that feeds the cause of guerrillas and other antigovernment groups. Consistent and positive movement towards change in the healthcare and rehabilitation of the poor and disabled could lend creditability to the democratic government of Colombia. Encouraging democracy and stability of institutions remains of paramount interest to Hanger RFD.
Developing the Needed Social Context
Hanger RFD is also concerned about developing the social context in which the project must also "develop." Sustainability and competent "hand-over" to full Colombian ownership depend on a proverbial Petri dish of necessary elements. The two medical students who have volunteered their time for this clinic were invited to sensitize the city beyond the camps to the plight of the refugees.
Many in the well-off strata of Barranquilla are not even aware of the camps or of the suffering that brought about their existence, although the effects of refugees and displaced persons are impossible to ignore. Reports of volunteers and other community members who joined our previous clinics have reached the ears of prominent Colombians. During our visit, we were asked to present a summary of the project to Barranquilla's equivalent of the Chamber of Commerce. At the end of the talk, they pledged their assistance.
We meet with a candidate for mayor running in part on the refugee problem. He says thousands of refugees and displaced persons have migrated to the Atlantic coast, mostly to Barranquilla.
"Our city now has more murders per capita than anywhere else in Colombia," he says.
|A child, one of many ravaged by scabies.|
"Even Bogotá?" I respond.
"Sí. The refugees come here; there is no food, no shelter, no water. They have no recommendation for a job, so no one trusts them. Their children begin to starve, so they do what they must to care for them. What would you do?"
What would I do? The cries of hunger, thirst and disease of your own sons and daughters must be quite compelling indeed! It leaves one to contemplate what laws of man could overrule them.
The US government is also concerned about child combatants. Perhaps as many as five to eight of our technician trainees will be attempting to start life over beyond the horrors of violence and deprivation they experienced as children forced into war. Eventually they will provide O&P and perhaps physical and occupational therapy services from a clinic and rehabilitation facility also sponsored, in part, under the grant. The 18 scheduled medical/rehabilitation visits will serve as teaching clinics to extend their education through the instruction of credentialed US practitioners.
Guerrillas, FARC Combatants
|A stray dog who poignantly illustrates the harshness of normal life in the camp.|
Recently many guerrilla and FARC combatants have walked out of the jungle. We are told the government policy is harsh if they continue to fight, but big-hearted if they turn themselves in. The new president is living up to the electorate's expectation of a dramatic change for the better. So far, the guerrilla and FARC are welcomed with open arms and the program is having a positive effect--at least from the government's perspective.
Establishing quality healthcare in a country whose government is not sound and secure--or remains tyrannical--provides little hope that positive change will occur beyond the pill taken or the shot given. Hanger RFD is long-term in scope. "Rehabilitation for Development" is not just a convenient name. The concept of change must begin with the pill or shot and then reverberate all the way through the social and governmental system, if suffering like we see daily in the camp is ever to be permanently relieved.
Jeff Fredrick, MS, CO, BOCP, is director of Hanger’s Rehabilitation for Development (Hanger RFD) and branch manager at Hanger Prosthetics & Orthotics, Tallahassee, Florida.