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Lebanon's bittersweet expertise in prosthetics helps amputees

As a result of past conflicts in Lebanon, organizations and government ministries have created a prosthetics sector that continues to advance and using its knowledge to assist not only Lebanese, but also Syrian refugee victims of war and those with congenital disabilities.
Ahmad Sadek, a 13-year-old Syrian boy, receives medical treatment from a nurse in a government hospital in Tripoli, North Lebanon June 4, 2012. According to hospital officials, Ahmad was wounded four days ago during shelling by government forces in the town of Qusair in Syria. REUTERS/Omar Ibrahim     (LEBANON - Tags: CIVIL UNREST POLITICS) - RTR332UZ

Hussein Ghandour moves quickly through the prosthetic workshop at the Nabih Berri Rehabilitation Compound (NBRC) in Sarafand, Lebanon, where he has worked building prostheses and orthoses since 2000. He demonstrates each step in making a prosthetic limb, from casting to the final result. Using only his right hand, Ghandour guides a sander to shave a colorful orthopedic device for a child.

Ghandour, 34, is used to working with only the right side of his body. He stepped on a land mine when he was seven years old and lost the bottom half of his right leg and his right arm. Nonetheless, Ghandour's life is normal. He is married, plays on a soccer team, has a job and recently welcomed his first son, Ali, into the world. For him, life is good.

The various conflicts marking Lebanon’s history have left deadly traces behind. The country’s 15-year civil war (1975-90), repeated invasions and attacks by Israel and the spillover from the current conflict in Syria have all contributed to making Lebanon a country of people who once were and are again in desperate need of life-saving and life-altering prosthetic devices.

Although mine injuries in Lebanon have dwindled to less than one victim per month, emergency programs are being set up to meet the urgent needs of Syrian refugees coming across the border with war injuries or congenital conditions requiring prostheses. The Lebanese face many challenges in managing and meeting this renewed demand.

More than a million Syrian refugees are estimated to be living in Lebanon, a country of only 4 million people before the Syrian conflict began. Among the refugees, 1 in 30 have been injured by war, according to a report by Handicap International (HI) and HelpAge International. In addition, 20% of refugees in Lebanon have some form of impairment, with 5.6% having a severe type.

There is only a limited number of organizations working with these refugees in need of prostheses. One of them is HI, which has been in Lebanon since spring 2012. HI provides a range of emergency services, including prosthetic fittings, to both Syrians and Lebanese. According to HI regional communication adviser Sarah Pierre, as of August 2014 HI staff had performed 130 prosthetic fittings, followed by rehabilitation and psychosocial support.

The needs are great, as are the challenges, but HI is so far coping, said Daria Mussienko, HI field coordinator. There is a limit, however, to what HI can do within its mandate, she told Al-Monitor. “We provide, in certain ways, limited support. People need health care that goes further, beyond our assistance. We’re not, for example, doing surgeries, and the needs for that are quite high,” said Mussienko.

The World Rehabilitation Fund (WRF) is an international nonprofit that has been working in Lebanon since the early 1970s. The organization recently finished a seven-month project funded by the UN Emergency Relief Fund to fit Syrian refugees and Lebanese in host communities with prosthetics, orthotics and other corrective devices, such as eyeglasses and hearing aids. In that time, WRF, working through local nongovernmental organizations and local service providers, delivered 853 devices for 738 people, with a focus on children and urgent cases; 153 of the devices were prostheses, according to WRF's assistant director, Toufic Rizkallah.

Rizkallah told Al-Monitor that it was most efficient to contract out such work because of knowledge of the sector, accessibility by beneficiaries and existing infrastructure. “Many of [the refugees] were injured in the war. Others had congenital deformations. Most of the children were not injured in the war, but needed orthotic prosthetics. They have some problems with scoliosis, cerebral palsy. … We focused mostly on children of school age, to go to school, and some special cases of adults, like a mother who cannot hear,” said Rizkallah.

Fatima, a 15-year-old from Homs, is one of the beneficiaries of WRF's work. Fatima lost the bottom half of one of her legs in a bombing in 2011. After several months in a Syrian hospital, she arrived in Tripoli, where she approached different organizations and dealt with two ill-fitting prosthetics before she got one that fit better through WRF.

Fatima and her family had been living in an apartment, but after her brother was killed and her father imprisoned, financial assistance from Syria dried up. They are spending their first winter outside this year. Despite the hardship, Fatima has gone from depressed to grateful and eager to somehow get back to school.

Sitting in her family’s small tent, rain pelting the tarp above her head, Fatima said to Al-Monitor, “Thanks to God, life is good. No problems. I walk normally now, … but I want to go back to school.”

Rizkallah said WRT was looking for more funding, but so far unsuccessfully. As applications pile up and calls come in daily, he worries that with shifting priorities in the region, it will become increasingly difficult to meet needs. Prosthetics require proper maintenance, especially those for young people. They might need a new artificial limb every year, but without funding, they will have to go without.

“The needs are increasing, the funds are decreasing. It will be a challenge. And the most affected will be these vulnerable groups. People with disabilities will be the most vulnerable,” Rizkallah said.

The local sector, as Rizkallah mentioned, has been crucial for refugee support and took many years to develop. Habbouba Aoun, coordinator of the Land Mines Resource Center at the University of Balamand, has been working with victims of land mines since the 1990s. During 1995-96, Aoun participated in a WRF project for the Ministry of Health to establish a national prosthetic and orthotic technical unit. With funding from the ministry, this unit would manage donations of prosthetic limbs and orthotics to people in need, create price lists and national standards. This was the beginning of the long journey this sector has made in the evolution of techniques and technology in this area in Lebanon.

In 1996, more than 800 prosthetic fittings were provided through the ministry. A year-end analysis found that 35% of those fitted with limbs were land mine victims, mostly from two districts in the western Bekaa Valley and Rashaya. When examined along with a survey of land mine victims in Lebanon with support by the Lebanese Ministry of Public Health and the World Rehabilitation Fund in 1996, it was found that out of 64 villages polled, 59 of them were blighted with land mines, unexploded ordnance, cluster bombs and other explosive remnants of war. Expanding the survey to cover the entire country revealed that Lebanon's needs were extensive.

According to the Lebanese Mine Action Center (LMAC), there were at least 100,000 mines and unexploded ordnance left from the civil war, and more than 550,000 anti-personnel and tank mines after Israel withdrew in 2000. An additional 4 million cluster munitions were fired into the south of Lebanon in 2006.

Despite these incredible numbers, mine risk education, mine clearance (by nongovernmental organizations and the Lebanese army) and increased public awareness have dramatically reduced the number of mine victims. Aoun touts Lebanon as a country that has greatly evolved to develop a deep knowledge of victim assistance, including support related to prosthetics.

Aoun told Al-Monitor, “Nationally and internationally, the science and knowledge of how to do mine action has developed a lot, from personal initiatives to a science, to a discipline. We have standards. We have lessons learned from other countries. … We were ignorant in mine action. … We developed knowledge. We can proudly say we became experts in mine risk education and victim assistance.”

Part of victim assistance includes WRF’s program on how to become a prosthetic specialist and how to operate a prosthetic workshop. According to Aoun, the program in Lebanon graduated enough prosthetic specialists to meet the needs of the country.

The Lebanese Welfare Association for the Handicapped (LWAH) is an NGO founded in 1984 by Randi Assi Berri. LWAH has greatly expanded since, building the NBRC in Sarafand, in the south, in 1996, which among many other specialties and services, hosts a prosthetic workshop where several people work, including Ghandour. They build a variety of prostheses, from standard devices to more expensive and versatile ones with hydraulics for athletes and young people. An expert comes in twice a week to train the prosthetic team in new techniques, equipment and technology.

Zeina Assi, projects manager at LWAH, told Al-Monitor, “[The prosthetics department] has grown on different levels, equipment as well as specialists. Equipment was very basic back in 2006, and since then we have acquired new equipment and new techniques and still look forward to soon changing the equipment for more advanced options.”

Ousama Fakih reattaches a prosthetic leg at the Nabih Berri Rehabilitation Compound’s prosthetic workshop in Sarafand, Lebanon. He has worked here since 1996. (Photo by: Melissa Tabeek)

LWAH has provided prosthetics to Lebanese and Syrians refugees through contracts with the Ministry of Health and NGOs. Last year, they distributed more than 80 prostheses and in 2014 delivered services through WRF’s emergency response project, according to LWAH’s 2013 annual report.

One of its more visible projects is the Landmine Survivors Club, established in 1999. Its support spans from income-generating activities to plays, seminars and sports. It started a soccer team in 2000. There is now a group of about 15 men who have been playing together for years. Nearly all of them have a prosthetic limb. Every Wednesday, they suit up in their red shirts, shorts and socks to train. Ghandour plays on the team.

On one particular Wednesday night in a small village outside Sarafand, it had gotten dark early. The white lights at Saloub Stadium illuminated the field as the men warmed up before beginning their scrimmage. The level of play was fast and skilled, with quick, give-and-go passing and hard shots on goal. One does not immediately notice that any of these men have a disability.

“Before this one day, maybe they are angry, but now, no,” Ghandour said of the days they play soccer together. “And sports are so important to support land mine survivors. When they see people like us play soccer, this gives them the strength to move on.”

Mohamed El Hajj, 50, was 20 years old when he became a land mine victim. His team is family, he said, and he comes out every week for the camaraderie and his love of the game. “I played football before the accident, and I wanted to continue,” Hajj told Al-Monitor. He had just participated in the Beirut International Marathon with other members of the Landmine Survivors Club.

Mohamed El Hajj takes a shot on goal on a Wednesday night at Saloub Stadium. Hajj lost his leg when he was 20 years old in a land mine accident. (Photo by: Melissa Tabeek)

When Hajj was first injured, the prostheses sector in Lebanon was still developing. Since then, much has changed, which Aoun says has been key in coping with the conflict in Syria. When refugees began to pour across the border, there was already infrastructure in place from Lebanon’s work over the past decades to deal with critical war injuries.

“When it came to Syrian refugees, we were, as Lebanese, able to share with them the knowledge we had of the rehab process and the services that exist in Lebanon, especially related to prosthetic services,” Aoun said. She also pointed out that life is becoming more expensive and more difficult for everyone in the country. She is determined to find funding and continue her work with land mine victims who need prosthetics and services, but she senses a long struggle ahead.

“I see more challenges in getting funding. We work through all of these international funds and donations. And with all the emerging needs in the area, what priorities are given to the country, Lebanon?” Aoun asked. “It means if I get less funding, I will have less ability to provide service. It means that deterioration will continue. You have to find more means, better means, to survive.”

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