Global policy and local actions for vulnerable populations affected by disaster and displacement

Abstract

The Universal Declaration of Human Rights ratified by the UN in 1948 encompasses the concepts of creating and enabling occupational opportunities including work, leisure, education and community participation (United Nations, 1948). The UN Declaration supports occupational therapists to act on behalf of our clients and our communities as well as diverse populations of vulnerable people. The World Health Organization (WHO) defines vulnerable people as children, pregnant women, elderly people, malnourished people, and people who are ill or immune-compromised (WHO, 2013). People with disabilities are included in this group and tend to be among the poorest of the poor (WHO, 2011). Poverty – and its common consequences such as malnutrition, homelessness, poor housing and destitution – is a major contributor to vulnerability. Natural and manmade disasters are affecting more and more people around the world. People are displaced from their homes and their lives, making them vulnerable. They may lose everything or be able to take only the basics with them. Livelihood opportunities may be destroyed. With lost roles and changed circumstances, survivors live perhaps in temporary housing in tiny rooms which take little time to clean, where there is no work, nothing to do, no occupational opportunities, a loss of daily structure, leading to boredom and despair (Wilson, 2011). With their support systems removed, displaced people are often unable to access basic health, welfare and education services. They experience severe socio-economic loss and impoverishment. How is the global community responding to this global crisis of displacement and vulnerability? What can we do as communities of professionals and as individuals? As a profession concerned with promoting health and well being through occupation, occupational therapists should be addressing issues that truly affect people's lives. In translating international policy into local action, we can fulfill many of the goals set out by the UN in their seminal document The Millennium Development Goals (United Nations, n.d.). Why do I comment on the MDGs, which were established in 2000 with goals set for 2015? How does this relate to the subject of this editorial – vulnerable populations and human displacement? I feel it is important for occupational therapists to understand global policy development so that we can better apply international principles to our own health systems and direct practices in order to effect change for our clients and communities. Much has been written in the international literature (now online) that supports the ongoing thrust of the MDGs to achieve global health and reduce poverty, partly because national and international organisations have to report to the UN regularly on their actions related to the MDGs and future goals (United Nations, n.d.), but also because there is increased interest worldwide among the general population. With easy access to online media, we are made instantly aware of the aftermath of disasters. Huge strides have been made so far in meeting the MDGs (United Nations, 2013). For instance, according to the Millennium Development Goals Report 2013, there have been visible global improvements in all health areas as well as in primary education. This includes halving the number of people living in extreme poverty. Some of this has been accomplished through financial input from major development organisations to reduce country debt. With continual global monitoring and evaluation, positive accomplishments can be tracked and supported. Now, UN agencies are looking to post-2015 actions for sustainable development goals to support and continue the actions already started. With the realisation that there must be policy and financial support from higher levels of government to effect change at community level, better coordination, better methods of monitoring, and improved policy at all levels are required to achieve the sustainable development goals. Another thrust at global level has been in direct relation to disaster mitigation. Global agencies have moved from talking about disaster relief and response to realising that disasters will happen but humans can reduce their impact through preparedness and changed ways of thinking. Change of thinking can lead to change in actions. One agency, the UN-based Global Network for Disaster Reduction (GNDR), started an online discussion to gain a clearer perception of the actions for change required at all levels from global to local. I was fortunate to be part of these discussions. One action undertaken by the group was to go to communities and community leaders to find examples of effective actions (Global Network for Disaster Reduction, 2011). Twenty thousand people from 69 countries responded to a GNDR survey and the results were compiled into Views from the Frontline. From this material, 90 case studies were produced, called Action from the Frontline, which share ideas and spur creative thinking. These case studies can be viewed at www.globalnetwork-dr.org. The GNDR research team found that different communities have different perspectives on their own needs (Global Network for Disaster Reduction, 2011). These case studies promote ways for communities to realise possibilities for reducing the effects of disaster – famine, epidemics, flooding – and make change to mitigate disaster risk. Based on their research results, GNDR brought community leaders together in regional workshops to share their ideas. With the authority of this agency, these ideas were conveyed to national and international levels through regional and world conference and online sharing which include community leaders, national and international NGO's. The 2012 World Disasters Report (International Federation of Red Cross and Red Crescent Societies, 2012) focused on forced migration and displacement. The work of the international community on reducing disaster risk and mitigating the impact of disaster is built on the knowledge and experience developed by countries and other stakeholders over the past several decades. Milestones include: in 1987, the 1990s was declared the international decade for natural disaster reduction (A/RES/42/169) by the United Nations General Assembly; in 1989, the United Nations General Assembly adopted the International Framework for Action for the International Decade for Natural Disaster Reduction (A/RES/44/236); in 1994, the Yokohama Strategy and Plan of Action for a Safer World was adopted by the 1st World Conference on Natural Disaster Reduction; in 1999, the United Nations General Assembly endorsed the International Strategy for Disaster Reduction (A/RES/54/219); and in 2005, in Kobe, Japan, the 2nd World Conference on Disaster Reduction adopted the Hyogo Framework for Action 2005–2015: Building the Resilience of Nations and Communities to Disasters (HFA) (International Federation of Red Cross and Red Crescent Societies, 2012). The Hyogo Framework for Action (HFA), a 10-year plan to make the world safer from natural hazards, will end its term in 2015. Thinking forward to post-2015 action has generated much discussion among stakeholders. Since the adoption of the HFA, the promotion of resilience has gained significant attention and investment, but there is disagreement about what resilience means and how it should be incorporated into the post-2015 development framework. Is the promotion of resilience a new approach that will bridge the divide between providing relief and promoting development, or is it a concept developed in the international aid arena to cover the real need for humanitarian response? Measuring resilience may be a way to determine its influence (Levine, Pain, Bailey & Fan, 2012). The proposed elements of a post-2015 disaster risk reduction framework include ways of fostering accountability so that responses are practical, specific and focused, measurable in progress, conform to agreed standards and certification and stimulate commitment by stakeholders. According to the United Nations Office for Disaster Risk Reduction (2013), the framework should enhance risk governance with public-private partnerships and support scientifically informed decision making. It should address the underlying cause of increasing loss from disaster and reduce vulnerability through the development of insurance schemes, training and information, social protection schemes and safety nets. Thus, disaster risk management would become a part of sustainable development. In these Frameworks for Action to reduce disaster risk, there should be particular note of the needs of people with disabilities as it has been found that, in developing countries, people with disabilities tend to be among the most vulnerable. People with disability account for between 15% and 20% of the global community and this figure is higher in a developing country context (WHO, 2011). The circumstances that people with disability consistently face include lower educational enrolment and attainment; limited employment opportunities; limited access to information, services and resources, and an increased likelihood of a life in poverty (Robinson, Scherrer & Gormally, 2013). People with disability may be placed at increased disaster risk due to cognitive, intellectual or physical impairments. These factors may limit the ability of a person to access information and/or to act on that information. For example, information on disaster preparedness may not be available in accessible formats so people with disabilities are less aware and less prepared for a disaster. Including people with disabilities into disaster planning and decision making processes should help to protect the dignity and rights of the most vulnerable members of the community. It will ensure that the skills and capacities of all community members are utilised in relief, recovery and reconstruction. It will also contribute to meeting the need created by increased numbers of people with disability in the community as a result of disaster. The World Federation of Occupational Therapists (WFOT) is the international representative of occupational therapists worldwide. Its objectives are to promote health, occupation and participation within a worldwide perspective; to increase and maintain the awareness, understanding and use of services of occupational therapists by government, employers and the wider community through collaborative action; to develop and promote a standard of excellence in occupational therapy practice; to ensure the ongoing development and accessibility of high quality education and research for occupational therapists worldwide; and to present the diversity of international or cross-cultural issues. WFOT is collaborating with multiple international organisations and contributing to the international discussion on areas of direct relevance to its objectives. The partnership with WHO's Disability and Rehabilitation Team (DAR), for example, provides an avenue for contribution, involvement, and forward planning on specific issues of disability, vulnerable groups, and disaster management. These issues have been noted in a number of occupational therapy papers. The WFOT Position Paper on Human Displacement, the WFOT Position Paper on Human Rights, the WFOT Position Paper on Cultural Diversity all refer to the problems which ensue from forced migration and consequent vulnerabilities. WFOT, through its position papers, offers support for occupational therapists to inform governments and strategic organisations of the role of occupational therapy in working with vulnerable and culturally diverse groups. The WFOT Guiding Principles on Diversity and Culture (Kinebanian & Stomph, 2009) offers suggestions and approaches to understanding cultural needs and human rights. The WFOT Position Paper on Human Displacement (2012) notes that occupational therapists respect occupational strengths by valuing previous life roles, occupational adaptation, and existing occupational participation. It affirms “reciprocity with displaced persons, partners, and host communities as normal means of reducing the impact of displacement for people and host communities affected.” The WFOT Position Paper on Human Rights (2006a) also supports occupational justice. The WFOT Position Paper on Community Based Rehabilitation (2004) notes, “Occupational therapists are committed to advance certain core principles, one of which is the right of all people – including people with disabilities – to develop their capacity and power to construct their own destiny through occupation”. The WFOT Minimum Standards for the Education of Occupational Therapists (2002) emphasise client-centered occupation-based practice. They offer an occupation-centred framework for students to work in novel practice areas, with diverse and vulnerable populations. The WFOT Disaster Preparedness and Response (DP&R) Information Package (2006b) is available to occupational therapists in countries affected by disaster or where DP&R training is taking place. This package was updated in 2012 with revised website and databases and a second edition is being considered. Regional and national workshops have been conducted by WFOT, or by national OT associations with the support of WFOT, to raise awareness and build capacity to work with vulnerable groups affected by disaster. These workshops have addressed prevention and risk reduction issues incorporating occupation-based principles. Workshops have been held at regional occupational therapy congresses, including the Asia Pacific OT Congress 2012, as well as World Congresses. Out of a workshop held after the WFOT World Congress in Chile in 2010, a regional group called TO en alert (Occupational therapists on Alert) was formed in South America. Members have shared information, research and actions for improved response to disaster related situations. Disaster Preparedness, Response and Recovery is one themes of the coming WFOT World Congress in Japan in June 2014. There will be a great deal of sharing related to the occupational therapy role in disaster management and risk reduction. Discussions will include concerns for human displacement and occupational justice issues. These exchanges will further inform the global occupational therapy community about working in this important field of practice. Occupational therapists are working with survivors of disaster, refugees and migrants around the world at the initial stages of natural disaster as well as at the stage when people become migrants and must adjust to new and sometimes frightening circumstances. In many situations OTs are supporting people and communities to help each other. OT intervention may include life skills training on an individual level or in groups, or provide train the trainer situations where skills can be passed on. As noted in this journal, OT students and practitioners work with diverse populations with multicultural backgrounds and needs. Examples of good practice in this area abound although they are not often written up in journals. It is often only at conferences – and now more often in online social media and blogs – that we learn of innovative practice. Seeking out opportunities to observe innovative practice in different countries, I have found excellent examples of approaches to mitigating vulnerabilities through ‘self-help’ and community practice. After the OTARG Congress two years ago in Zambia, I had the privilege of visiting a remote village to observe a feedback meeting of a local NGO self-help group. The discussion centred on abuse of women and girls. The meeting started with a drama put up by the local school children. It carried through the day with small group discussion and feedback. Some 40 villagers had come from a 10 mile radius to attend the meeting. They live in arid farmland and eke out a subsistence living. The Response Network in Zambia is an excellent example of local action. Though it does not have an occupational therapist directly involved in their activities, it embodies many of the principles of occupational therapists working in community development and is based on international policy. It is a rights-based organisation which is involved in helping people to know their rights with regards to education and living with dignity. Focused on facilitating village self-help programs, they use a structured method of encouragement and information delivered by skilled facilitators to motivate villagers to start and run self-help activities to improve their life situation. Locally developed manuals provide information on how to start and run self-help clubs within a variety of thematic areas, including community schools, adult literacy, skills training, know your rights, women's rights, health and nutrition, organic growing, HIV/AIDS, children with special needs and sports. By helping villagers to understand that they have many skills and resources themselves, facilitators help villages realise that they can solve most of their own problems without depending on outside donors. From 2005 to 2012, the Response Network has facilitated village programs in more than 600 villages. These villages have started over 3000 self-help clubs with over 60,000 members, building confidence, knowledge and skills and improving their life situation (Response Network, http://responsenetwork.org/). This self-help approach could easily be translated into other situations working with vulnerable groups. This year, after another very successful OTARG Congress, this time in Zimbawe, I had the opportunity to stay in Cape Town in South Africa and visit the Grandmothers Against Poverty and AIDS (GAPA), an NGO started by occupational therapist Kathleen Brodrick (2004). GAPA is a community-based support programme for grandmothers of small children and teenagers who have lost their parents to the long-term epidemic AIDS. The project, in a township near Cape Town, brought together depressed, distressed and frustrated women through a familiar occupation – patchwork quilting. Today all over South Africa there are grandmothers holding together families affected by HIV/AIDS and poverty. Often these women are the sole bread winners in a household. They may also be nursing the dying and bringing up orphaned grandchildren on their own. Research shows that these grandmothers suffer from a lack of information, stigmatisation and overriding poverty (GAPA, http://www.gapa.org.za/). Four-day workshops are held each month for grandmothers who are new to the project where they learn about HIV infection and AIDS. Practical skills to overcome effects of the pandemic on households are taught. The workshops cover topics such as HIV/AIDS and cancer awareness, vegetable gardening, human rights, elder abuse, death and bereavement, drawing up a will and business skills. Grandmothers are also invited to attend support groups held in the homes of area representatives once a week. GAPA's motto is ‘together we are stronger’ and the aim is to draw on the inherent strength of the grandmothers in the community to bring lasting change and hope. This NGO, which started with a small group of women and a vision, has now grown to become international. The UN is assertively addressing global issues of poverty and inequity while identifying specific goals and monitoring progress toward meeting those goals at an international and national level. Using the documents and reports of international policy already established in high level meetings, occupational therapists can translate these principles into local action. Occupational therapists need to be aware of global issues and documented strategies in order to devise better approaches to increasing individual occupations and removing societal barriers that inhibit participation. Occupational therapists must work collaboratively with vulnerable people, whether they are migrants, survivors of natural disasters or epidemics, or living at subsistence level in difficult situations. Occupational therapists need to have an understanding of their needs and cultural perspectives to assist in promoting occupational engagement and participation. WFOT documents are useful to support such actions. The articles in this journal offer further examples of local action incorporating international policy.