Book Review: Disability in Afghanistan
By M. Miles (email@example.com)
Majid Turmusani (2006) Disability Policy Development in Afghanistan. A manual for planners. Burnaby, Canada: Asian Research Service. isbn 9622340660. xii + 187 pp.
This small book compiled by Majid Turmusani (with one chapter by Italian contributors, A Micangeli & F Pietrantonio) is not a ‘manual for planners’ in the sense of a compendium of practical wisdom developed through long experience of formulating realistic and workable disability-related plans appropriate to countries with modest financial resources and limited infrastructure. It is a work-up of various documents compiled and studies conducted during 2003, when some groups of service-providers and disabled people’s organisations, mostly within reach of Kabul, took part in consultations to formulate a national policy for the Ministry of Martyrs and Disabled , culminating in the "Comprehensive National Disability Policy",  largely drafted by Dr Turmusani and completed late in 2003. The woes and darkness of the country situation are comprehensively bewailed. The cultural traditions, personal resources and strengths found in ordinary Afghan families are mostly ignored. The highest rhetoric and baloney of western UN conventions, ideals, human rights and the social model of disability are parachuted in like a ‘cargo cult’ for the natives to perform dances around.
This book was compiled and published in locations not under immediate bombardment. In Burnaby, Canada, there must surely be electricity and computing facilities. Yet the production is slapdash, apparently without benefit of editing and proofreading. (Even the people whose help is acknowledged don’t all get their names spelt correctly). Perhaps the idea is to reflect the magnificent chaos within Afghanistan, and give a short performance of anger toward ‘civilisation’ and its contemptible luxuries of clean water, newspaper cartoons, and spell-checkers. An anthropologist’s anecdote tells of a Pakhtun elder, for whom the ultimate degradation, in the namby-pamby younger generation that was ruining the world, was the habit of eating tomatoes. Sickening! What would such an elder make of laptops and wireless mice? [Thus, to complain that the book under review is full of abbreviations but no list is given, would be utter wimpishness. A few, like GVC (pp. 17, 38, 110, etc) can be decoded -- obviously GVC must be Civic Voluntary Group, as it appears in the list of References; or maybe Civil Voluntary Group (p. 114)? You have to be Italian, fully to understand these things.]
Rhetoric, Cold Sponge, CBR
It is hard to know what to make of this paradoxical attempt to sustain the highest rhetoric of democratic participation, individual human rights and the ‘social model’ of disability, in a situation ostensibly characterised by the humiliation and powerlessness of the mass of ordinary people, a sharp reduction of the communal rights that Afghan cultures have traditionally provided, and the destruction of broad cultural features that would lend coherence to the notion of an Afghan ‘society’, rather than an agglomeration of warring factions. At a few points, the warmed-over rhetoric is given a cold sponge on the neck. The (interim) Ministry of Public Health, after listening to many interest groups, decided that disability and mental health problems did not yet "constitute a priority for the Basic Package of Health Services" in Afghanistan (p. 37). An evaluation team had some disabled people added to lend it credibility, but the researchers found these partners devoid of research skills, so merely used them as informants (p. 128). A government Working Group on Policy Research in the disability field recognised a need for policies and strategies to be based on detailed study of the actual situation of disabled Afghans, rather than guesswork by ‘experts’ flown in from wherever; also that "Importing certain model/s even from the most advanced societies and apply it to Afghanistan would not be something wise to do as substantial variations and differences between societies do exist." (p. 179) [!]
"Something wise to do" is not always found. The people of Afghanistan will live or die in their own ways, wise or otherwise, regardless of bombs and foreign experts. However, in chapter 6, on Community Based Rehabilitation, the author does make a more intelligent appraisal of strategy and resources, and fleetingly recognises that "Medical and social views can complement each other in the field of rehabilitation" (p. 122, footnote). The term "community based rehabilitation" lost any specific meaning at least 15 years ago, and is now redefined on the spot by anyone stumbling across it. Dr Turmusani makes some assertions about what CBR is for, and what he considers to be its most important features. Yet only two things are predictable for how CBR can be practised here. In most of Afghanistan, it will be hard for male CBR workers to enter people’s homes and work with disabled females, or with female family members. And female CBR workers will have more difficulty travelling about, to reach disabled people in their homes. Nevertheless, some earlier schemes of primary health care proved workable, without too flagrantly crossing cultural boundaries. Traditional midwives have also continued to move within local communities. It is possible to learn from earlier experiences, unless one has a fixed belief that nothing of any merit could ever have been done before one’s own arrival on the scene.
Information and Benefit
The benefit of the book may be that it does give an unusual insight into the kind of muddled advice and ideological advocacy that sloshes around in the make-shift government offices of damaged countries where ‘reconstruction’ is being tried but where there is little evidence or reason to think it will develop quickly enough to prevent a slide back into chaos; and where there are powerful forces having no interest in, or a powerful antipathy toward, the kind of westernising slogans around which reconstructive efforts are funded. Visiting capital cities in such situations is unpleasant and dangerous. Spending several months in them greatly increases the uninsurable risks of being blown up or taken hostage, with no compensatory gain in knowledge of how to plan well for the country’s future, nor any more than a faint possibility that one’s work will have the slightest effect on that future. Such circumstances have some appeal to the young and adventurous, who thrive (for a while) on adrenalin and permanent emergency; but are seldom attractive to people having substantial experience of advising governments for peace-time development, especially in the disability sector, usually the icing on the cake after much broad infrastructure has been established.  Typically, the advisor is shown a small room with blown-out windows, a rickety table and a pad of notepaper (dried out after some kind of flood); and is requested to provide a national plan by the end of the month. C’est magnifique, mais ce n’est pas la paix.
Sifted and distilled evidence and information does exist on some aspects of disability in Afghanistan, and is not all hard to locate. Some is listed on the internet (e.g. http://cirrie.buffalo.edu/bibliography/afghanpakistan/index.html). Some has long been available at ARIC (Peshawar), and its successor, the Afghanistan Centre at Kabul University (ACKU) www.afghanresources.org, with online catalogue. Some appears in medical journals, which increasingly often may be free online some months after publication. Perhaps published research has little impact on government policies in developing countries; yet it is hard to know why Dr Turmusani did not, at least retrospectively, list some more solid evidence in the descriptive sections of his work. Those sections have plentiful mention of ‘rights’ and the ‘social model’, citing ‘authorities’ who have never visited or even imagined Afghanistan. Yet when glancing, for example, at the neglect of mental health and possible large-scale traumatisation and after effects (pp. 20, 28, 31-32), there is no mention of peer-reviewed published evidence, such as the Afghanistan national survey of basic mental health in 2002 and partial report in a medical journal (Cardozo et al, 2004; see also Rasekh et al, 1998).
There is nothing intrinsically evil about studies using medical terminology! In a nation so damaged that ‘society’ hardly exists as a coherent entity capable of acting to improve the lot of disabled people, it seems perverse to dismiss medical studies in favour of a notional ‘social model of disability’ that is incomprehensible within the country. The development of the ‘social model’ took place in lands where basic health, education and welfare services were taken for granted, and had been available countrywide for decades. Better to face reality in Afghanistan and start with the available data and the informal resources of the people themselves.  Yet Turmusani assures readers that, for example, "Until now, there are no studies on the situation of disabled women in Afghanistan." That is not so; for example, Habibi (1989) has written directly about disabled women; Lambert et al (1997) studying physical disability in households, reported on the situation of disabled women, as have other researchers. Turmusani himself praises the articulate leadership of the National Association of Disabled Women in Afghanistan (p. 83). A striking series of interviews by Rostami Povery (2003) among women in Kabul further makes apparent the inappropriateness of separating Afghan women with serious impairment of body from others with crushing ‘social’ disabilities, and others again who might classify themselves in quite different roles. The status and roles of Afghanistan’s women have been sufficiently misunderstood by "well intentioned" but "ill-informed" aid advisors, as detailed by Barakat & Wardell (2004).
However, the process of creating a National Disability Policy, amidst turbulence and uncertainty, no doubt served to focus some attention on this area, and provided a reference document and some momentum. In March 2005, a 3-year National Programme of Action on Disability was launched, between the MMD and the Ministry of Labour and Social Affairs. One of the much-needed goals is "The formation of an accessible national knowledge bank based on in-country disability information" and on other sources, as has been recommended regularly for at least the past 12 years (Miles, 2003). Some progress has been made towards this (UNDP Afghanistan, 2005). The challenge is admitted, on the policy front, of the government’s "very low starting point of understanding of disability and the needs of disabled people; and the extremely low technical capacity to provide leadership in policy and programme development which may slow delivery rate and achievement of outcomes." The speed of understanding might have increased if the original policy discussions had used terms having easier recognition by government officers and greater credibility with all parties. Nevertheless, some progress is being made, subject to funding, and to intervals of peace between the outbreaks of fighting.
 Armstrong & Ager (2005, p.88) refer to "the emergence of organizations for PWD such as the Ministry for Martyrs and Disabled (MMD), which through their titles, linked disability with political struggle." The actual M of MD (not for MD) might be amused to be identified as a disabled people’s organisation. It is certainly a government ministry of Afghanistan, not a non-governmental organisation.
 "The Comprehensive National Disability Policy in Afghanistan, submitted to Minister of Martyrs and Disabled, Kabul, October 2003".
 In 2005, Ferneeuw (p.13) noted that "Currently, we could feel segregation in the discourse of different ministries: "let us treat the problem for the main population first and we will try to see after for the disabled."
 Another reality was discovered after the movement described by Turmusani for ‘participation’ of disabled people in formulating the National Policy. The idea came up that disabled people’s organisations should take over management of CBR services, hitherto run by experienced international non government organisations under the UNDP umbrella. "This proposal has not been materialized as the UN was in favor of capable INGOs" to continue running services, in the event of normal government resuming and UNDP’s role being reduced (p. 125).
Armstrong J & Ager A (2005) Perspectives on disability in Afghanistan and their implications for rehabilitation services. International J. Rehabilitation Research 28: 87-92.
Barakat S & Wardell G (2004) Exploited by whom? An alternative perspective on humanitarian assistance to Afghan women. In: S Barakat (ed) Reconstructing War-torn Societies: Afghanistan, 109-130. Palgrave Macmillan.
Cardozo BL, Bilukha OO, Crawford CAG, Shaikh I, Wolfe MI, Gerber NL, Anderson M (2004) Mental health, social functioning, and disability in postwar Afghanistan. J. American Medical Association 292 (5) 575-584.
Ferneeuw S (2005) Physical Accessibility and Disability in Afghanistan. Diagnostic and workshop report. Lyon: Services Techniques et Etudes pour la Participation Sociale.
Habibi GS (1989) Disability among Afghan Women - its impact on child survival and development and quality of life of the family. New York: UNICEF.
Lambert ML, François I, Salort C, Slypen V, Bertrand F & Tonglet R (1997) Household survey of locomotor disability caused by poliomyelitis and landmines in Afghanistan, British Medical J. 315 (issue 7120): 1424-1425. http://bmjjournals.com/contents-by-date.0.shtml [and navigate]
Miles M (2003) Formal and informal disability resources for Afghan reconstruction. Zeitschrift Behinderung und Dritte Welt 14/1: 16-26.
Rasekh Z, Bauer HM, Manos MM & Iacopino V (1998) Women’s health and human rights in Afghanistan, J. American Medical Association 280 (5) 449-55.
Rostami Povey, E  Women in Afghanistan, passive victims of the Borga or active social participants? Farzaneh [Journal of Women’s Studies and Research in Iran and Muslim Countries] 6 (no. 11) 7-25.
www.farzanehjournal.com/ [select Archive]
UNDP Afghanistan  National Programme for Action on Disability (NPAD).