Community Based Reha bilitation

Under Conditions of Political Violence:

A Palestinian Case Study

Sandra Ballantyne

A thesis submitted to the School of

Rehabilitation Therapy

in confomity with the requirements for

the degree of Master of Science

Queen's University

Kingston, Ontario, Canada

May, 1999

copyright O Sandra M Ballantyne, 1999

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ABSTRACT

This study was undertaken to investigate the appropriateness of cornmunity based

rehabilitation (CBR) under conditions of political violence. A qualitative case study was made of

the CBR programme of the Union of Palesthian Medical Relief Committecs. The programme

developed under conditions of military occupation and popular uprising (the Intifada), during which

injuries and new disabilities overwhelmed existing medical and rehabilitation services.

A detailed description is provided of the Palestinian experience of CBR, and of the contlict

conditions that influence. its development. Specifically, conditions of repression and resistruice

affectecl individual elemcnts of CBR, and programme participants responded in a varicty of ways to

the obstacles encountered.

While obstacles were rife, it became apparent that the Intifada presented positive factors

for the development of CBR, such as heightened community capacities and the oppominity for

social change. Using the perspective of CBR as community development, the Capacities and

Vulnerabilities Analysis (CVA) framework provided a theoretical bais by which to explain the

study findings.

The findings of this midy indicated that, for a case within the Palestinian Intifada, where

community social/organizational and attitudinaVmotivationa1 capacities were high, a CBR

programme with a community developrnent approach was successfully developed. The

'<ippropnateness," then, of CBR under conditions of political violence can be understood in terms

of its contribution to cornmunity development. With this in mind, it was concluded that several

factors be assessed before endorsing a CBR initiative in a region of confiict. These factors hclude

the community capacities and wlnerabilities, the type of conflict, the elernents of CBR to be

pnontized in a pa~icular project, and contexaial factors such as culture.

ACKNOWLEDGEMENTS

1 sincerely thank:

my supe~sor, Will Boyce, for his rigour and compassion,

my study respondents, especially Dr. AIlam Jarrar and the UPMRC CBR team rnembea, for

sharing their experiences, knowledge, and insights, in the midst of busy and trying times,

my family and fiiends, for continuing to believe, and

my colleague, confidante and husband, Ibrahim, for giving me data, encouragement, new horizons,

and Khalil.

4.1.4 Summary ..................... .. ....................................................................................... 37 ................................................................ 4.2 Contextual Factors Anecting CBR in Palestine 37

............................................................ 4.2.1 Palestinian Culture - Support and Authority 37 4.2.2 Regional and Community Characteristics - Geo-political and Economic Disparities .. 39

...... 4.2.3 Professionalization and Institutiondiration o f Disability - Privilege of Expertise 40 .......................... 4.2.4 Attitudes Towards People with Disabilities - Tradition and Charity 41

............................................................................................................ 4.2.5 Summary 4 3 ......................................................................................... 4.3 Political Violence and CBR 4 3

......................................................................... 4.3.1 The Conditions of Political Violence 43 .................... 4.3.2 Effects of the Conditions of Confiict upon the CBR Work Environment - 47

4.3.3 Effects of Political Violence on CBR Elements .......................................................... 50 4.3.4 Political Violence and CBR: Surnmary of Findings ................................................... 75

.................................................................................................. CHAPTER 5 DISCUSSION 78

.............................................................................. 5.1 Design Issues and Smdy Limitations 78 ..................................................................................................... 5.2 Discussion of Findings 79

5.2.1 ThcRealmsofCommunity: UnderstandingCBRandtheIntiFada ............................. 80 5.2.2 Capacities and Vulnerabilities, and the UPMRC Response ........................................ 85 5.2.3 Comrnunity Development as Political Action ........................................................... 90

........................................................... 5.2.4 Conflict and Development - a Place for CBR 91 ............................................................................................ 5.3 Conclusion and Implications 93

................................................................................................................ REFE RENCES 9 5

.................... APPENDIX 1 . CAPACITlES AND VULNERABILITIES ANALYSIS 105 ..................................................... APPENDJX II . INTERVIEW QUESTION GUIDE 106

................................................................ APPENDIX III . DATA ANALYSIS TOOLS 108 .................. ................ APPENDIX IV . INFORMATION AND CONSENT FORM .. 1 11

LIST OF TABLES

................................................................ Table 3.1 Description of InterMew Respondenîs 22

Table 4.1 Regional Catchment of CBR Teams .................................................................. 32

......................................................... Table 4.2 Characteristics of UPMRC CBR Workers 36

............................................................................... Table 4.3 CBR Programme Activities 36

........................................................... Table 5.1 CBR Elements as Realms of Comrnunity 81

.......................................... Table 5.2 Capacities in Palestine for the Development of CBR 86

.................................... Table 5.3 Vulnerabilities in Palestine for the Developrnent of CBR 87

LIST OF FIGURES

...................................... Figure 4.1 The Position of CBR within the UPMRC Organization 30

Figure 4.2 Map of the West Bank, Showing Catchent Areas of CBR Projects .................. 31

................................................................................. Figure 4.3 Participants and Linkages 33

Figure 4.4 Structure of the CBR Programme ...................................................................... 35

LIST OF ABBREVIATIONS

AIPPHR

CBR

CNCR

CVA

GUPD (GUDP)

IDs

I L 0

NGO

PASSIA

PHC

RI

RW

UN

UNCTAD

UNDP

UNESCO

lMHCR

UNICEF

UNRWA

UPMRC

VHW

WHO

Association of Israeli and Palestidan Physicians for Human Rjghts

comrnunity based rehabilitation

Central National Cornmittee for Rehabilitation

Capacities and Vulnerabilities Analysis

Gencral Union of Pafestinian Disabled

(Later became the Generai Union of Disabled Palestinians)

identity cards

Internat ional Labour Organization

non-govemmental organization

Palestinian Acadcmic Society for the Study of International Mairs

primary health care

Rehabilitation International

rehabilitation worker

United Nations

United Nations Commission on Trade and Development

United Nations Development Program

United Nations Educational, Scientific and Cultural Organitation

Ulited Nations Hiçh Commission for Refbgees

United Nations Childrcn's Fund

United Nations Relief and Works Agency for Palestinian Refugees

Union of Palestinian Medical Relief Cornmittees

village health worker

World Health Organization

vii

CHAPTER 1

INTRODUCTION

1.1 Statement of the Problem

Worldwide, the scope and impact of war are tremendous. Codict causes disability in

many ways, and it has grave consequences for people witb disabilities who are caught in the

violence. Most conflicts occur in developing countria, where disabled people arc particularly

disadvantaged. While community based rehabilitation (CBR) was estabiished as an approach for

providing accessible rehabilitation services within developing countnes, the appropriateness of the

CBR approach to situations of political violence is unclear. It may be naive to expect communities

that are under extraordinary stress to sustain community based rehabilitation initiatives. On the

other hand, it may be that essential resources are still to be found within families and communities.

1.2 Study Purpose and Questions

The purpose of the current study was to provide a description of a CBR programme that

developed and operated under conditions of political violence. Further, the study \vas to allow

those involved to interpret the elements of CBR within their situation, leading to an understanding

of the relevance of CBR under conditions of conflict. The study sought to answer the questions: 1s

CBR an appropriate rehabilitation response under conditions of political violence, and if so, how is

it appropriate? These questions were answered using a case study of a Palestinian CBR

progranune that was implemented during conditions of occupation and uprising.

1.3 Relevance

Rehabilitation worken who practise, or seek to practise, in regions expenencing violence

will benefit from a description and an explanation of how CBR elements are affectai by such

conditions. The study provides them with greater knowledge with which to judge the suitability of

CBR, allowing more infomed choices in the utilizition of its approach. In addition, this study

contributes to the academic and professional field of rehabilitation theapy by furthering discussion

of the philosophy and practice of CBR. These contributions support the decision-making processes

surroundhg programming and policy-rnaking for rehabilitation efforts occumng in circumstances

of political violence.

CHAPTER 2

LITERATURE REVIEW

2.1 Community Based Rehabilitation

Community based rehabilitation represents a response, in boib developed and developing

countries, to the need for adequate and appropriate rehabilitation services, to be available to a

greater proportion of the disabled population (Peat, 1991, 1997). Within developing nations, CBR

atternpts to meet the ovenvhelming need for rehabilitation services, reaching the tremendous

numbers of disabied pcrsons who have lirnited or no access to such resources. Estimations are that

only 1 to 3% of disabled people living in developing countries who require rehabilitation seMces

receive thern, these services being panicularly inaccessible to the mral majority (World Health

Organization W O J , 198 1 ; H elander et al., 1 989; Peat, 1 997).

What cxactly constitutes the principles of CBR is the subject of much discussion. The

joint position paper of the International Labour Organization (ILO), the United Nations

Educational, Scientific and Cultural Organization (UNESCO) and the WHO (1994) has dcfined

CBR as "a strategy within community development for the rehabilitation, equalization of

opportunities and social integration of al1 people with disabilities ... implemcnted through the

combined efforts of disabled people themselves, their families and comrnunities, and the

appropriate health, education, vocational and social services" (p. 2). The WHO has contrasted

CBR with institution-based and outreach seMces of rehabilitation, in that there is a large-scale

transfer of knowledge about disabilities and of rehabilitation skills to the people with disabilities,

their b i l i e s , and members of the community (Helander et al., 1989). Jn this way, resources are

made available at the community level, and rehabilitation has been "democratized" (p. 3).

Einer Helander (1992) highlights the founding principles of CBR as being equality, social

justice, solidarity, integration and dignity for people with disabilities. In his detailed definition of

CBR, Helander (1993) States that CBR "is a strategy for improving service delivery, for providing

more equitable opportunities and for prornoting and protecting the human nghts of disabled people"

(p. 3). He goes on to Say that

It calls for the hi11 and cuordinated [sic] involvement of al1 lcvels of society: cornmunity, intermediate and national. It seeks the integration of the interventions of al1 relevant secton - educational, health, legislative, social and vocational - and aims at the niII representation and empowerment of disabled people. Its goal is to bnng about a change; to develop a symm capable of reaching al1 disabled people in need and to educate and involve governments and the public, using in each country a level of resources that is realistic and maintainable.

David Werner (1990a) proposes two goals of rehabilitation at the community level. The

first goal is '20 create a situation that allows each disabled person to live as fulfilling, self-reliant,

and whole a life as possible, in close relation with other people," and the second goal is "to help

other people - family, neighbours, school-children, members of the cornmunity - to accept,

respect, feel cornfortable with, assist (only whcre necessary), welcome into their lives, provide

qua1 opportunities for, and appreciate the abilities and possibilities of disabled people" (p. 6). in

addition, Werner stresses the importance of disabled people being leaders and workers in

rehabilitation activities, of rneaningful work and training for disabled people, and of local resources

being used for rehabilitation equipment and aids.

Rehabilitation International (RI) and the United Nations Children's Fund (UNICEF)

Technical Support Programme assert that CBR is based on the development concept of individuals

with disabilities becoming empowered to take action to improve their owvn lives and become

contributors to society (RINNICEF, 1989-90). In Canada, the International Centre for the

Advancement of Community Based Rehabilitation (ICACBR, 1993) has outlined pnnciples of a

CBR programme, which include change in community attitudes towards disability, empowement

of people with disabilities, participation and partnership in programme implementation and

development, and education (see also kat, 1997, p. 32).

Drawing upon an emerging consensus in these sources, then, a usehl list of key elcments

of CBR has been formed. These eight elements provide a framework for discussing CBR within

this study. A CBR programme is characterized by the following key elements:

a) Promoting positive community attitudes towards disability

b) Promoting integration of people with disabilities within society

c) Transferring rehabilitation knowledge and skills

d) Providing participantdirected rehabilitation seMces

e) Implementing the programme with community participation

f) Exhibiting a modcl of partnership among people with disabilities, families, the

comrnunity, and rehabilitation personncl

g) Using locally made rehabilitation aids and equiprnent

h) Participating in a referral network with specialists and institutions, for professional and

technical rchabilitation support.

It has oftcn been statcd that there is no bluepnnt for a CBR project (Peat, 199 1; Helander,

1993). This is bccause countries, regions, and cornmunitics Vary enonnously with respect to their

culture, political structures, populations and their distribution, and financial and workforcc

resources. Each of thesc circumstances will direct the nature of a "community based" programme.

In many societies, however, conditions of political violence overlie or disrupt these circurnstances.

Increasingly, a cornmunity-based approach to rehabilitation has been advocated in such conflict

conditions (ICACBR, 1996; Peat, 1997; Peat et al., 1997; RI/UNICEF, 199 1; UMICR, 1992;

UNRWA, 1992; Werner, 1990b; see also Boyce & Ballantyne, 1997).

2.2 Political Violence - Definition and Scope

In the search for a term that encompasses such diverse States as Ml-scale armed conflict,

rnilitary occupation, or popuiar rebellion, it is helpfûl to use political violence, as described in the

epidemiological work of Zwi and Ugalde (1989, 199 1). In an examination of impacts upon public

health, they discem four major forrns of political violence: stnictural, repressive, reactive, and

combative. These oEer a description of political violence ranging from imposed societal inequities

in resources and power (structural political violence, see also Agerbak, 1996), to the processes of

militarization and war (combative political violence), This framework inchdes violent acts by the

state, or opposition groups, such as political assassinations, torture, disappearances, dçtention, and

harassrnent (repressive political violence). Also included is violence against the state in the forrn of

coups d'etat, gemlla hvarfare, and revolutionary force (rûlctive political violence). It is helpfùl to

use the term political violence, to avoid a narrow interpretation that may arise when considering the

diverse experiences of populations under conditions of 'war.'

A consideration of the conditions and effects of political violence is highly impomt within

our international context, because the crisis is widesprcad. The Unitcd Nations Development

Program (UNDP, 1994, p. 47) notes that 42 countries expcrienced 52 major conflicts in 1993, a

further 37 countnes expcricnced '*political violence", and of these 79 countries, 65 were in the

developing world. In thcse developing countries, victims are from pwr families, who cannot flee,

are therefore at greater risk of death and injury, and are less able to access rehabilitation seMces

(Machel, 1996; RI/UNICEF 1991).

Victims of modem war are largely civilians, and the most vulnerable of these are children

and women. While in World War 1, 5% of casualties were civilians, in Wortd War II this figure

was 50%, and presently 80 to 90% of war victims are civilians (Agerbak, 1996; Ahlstrom, 1991;

Cairns, 1997; UNICEF, 1986a). The technology and tactics of modem conflict target the social

Uifrastructure of the enemy. This entails destroying communication facilities, roads, bridges, and

power generating plants, to shaner the economic base and the morale of the civilian population

(UNICEF, l986a). Civilians are not merely indirectly affectai, but are a strategic focus. Targets

are schools, hospitals, health workers, and children (Machel, 1996; Nixon, 1990; WUNICEF,

199 1; UNICEF, 1994). Atrocities against civilians are designed to undermine the sense of society

which could help to build peace again (Cairns, 1997). Even "low intensity conflict" serves to

burden the enemy with an injurcd and disabled population (Aston, 1992; Carey, 1990; Coupland

and Korver, 199 1 ; Garfield, 1989; Lundgren and Lang, 1989; Werner l99Ob). In such cases, the

violence is designed "to infiict maximum damage while minimizing the nsk of death" (Physicians

for Human Rights, 1988).

UNICEF (1996) has estimated that 400,000 people died per year in wars in developing

countries, fiom 1945 to 1996. Others note a drunatic increase in the last decade, with more than a

million per year for the nineties (Cairns, 1997) and 4 million deaths as a resuk of ethno-political

wars in 1993-94 alone (UNDP 1994, p 49). UNICEF notes that for eveiy child killed by war, three

more are seriously or pemanently disablcd, resuiting in 4 million childrcn physically disabled and

10 million psychologically traurnatized by war during the 1980's (Machel, 1996; UNICEF, 199 1).

Evidcnce fiom Afghanistan showcd that thc incidence of disability nearly doubled among children

living in zones of armed conflict (LTNICEF, 1990).

Despite the great numbers and drastic situation, little data is available regarding injuries

and the extent of rehabilitation nceds. Reasons cited for this include: the lack of tirne and energy

for information collection during the chaos of war, bamcrs irnposed upon personnel which fotbid

travel to remote locations where civiliûns are under attack, the low priority placed upon concems of

disabled individuals (especially women and children), and rnethodological concems (Boyce &

Weera, 1998; WUNICEF, 199 1; Giacaman & Daibes, 1989). In ongoing war, epidemiologists

face the special problems of continuous change where long term planning is virtually impossible,

military sensitivities impeding data collection, and necessary compromise wvith respect to scientific

rigour (Annenian, 1989). Available statistics should also be interpreted carehilly, as they can be

used by opposing sides as 'political wcapons7' (Rigby, 199 1, p. 87).

2.3 Political Violence and Health

The pemicious effects of political violence upon the health of a population are direct, in

t e m of injuw and destroyed health facilities, as well as indirect (Black, 1993; Carballo et al.,

1996; Garfield, 1989; Godfiey & Kalache, 1989; ltyavyar & Ogba, 1989; Lundgren & Lang,

1989; Machel, 1996; Macrae & Zwi, 1994; Rautio & Paavolainen, 1988; Ruff & Ward, 1991;

Siegel et al., 1985; Toole a al., 1993; Zwi & Ugalde, 1989, 1991). The indirect impacts of

political violence greatly outweigh the direct effccts, and daim more victims. Disruptions to food

production and distribution, water and waste systems, shelter, transportation and communication,

health services and the environment have serious and long-lasting consequenccs. Poverty and

persistent econornic trouble are associatcd with high military e'tpenditures, and urban and rural

destruction. When it is considered that most situations of armed conflict occur in developing

nations, the nsks become even more alamingly evident. Conditions of political violence introducc

or wonen malnutrition, starvation, the spread of infectious and pamitic diseases, injury, mental

illness and despair.

2.4 Political Violence and Disability

2.4.1 Direct and Indirect Effccts

Disability can also be a direct or indirect consequmce of political violence (Crisp, 1989;

RIRTNICEF, 1991). Impairrnents and disabilities caused directly by conflict are frequently a result

of orthopaedic trauma (especially of the limbs, and including amputation), spinal cord injury, head

injury, peripheral nerve injury, eye injury and hcaring damage, bums, respiratory complications,

and psychological and emotional trauma (Lundgren & Lang, 1989; WUNICEF, 199 1 ; UNICEF,

1994; Wemer 1 WOb). The nature of these irnpairments depends upon the characteristics of the

wnfiict, and the use of various explosives, landmines, fir~anns, instruments of beating and torture,

and tear gas (Habibi, 1994; Richman, 1995; Schaller & Nightingale, 1992; UNICEF, 1994).

Disabilities which are indirectly causeà or exacerbated by political violence relate prirnanly

to malnutrition (e.g., disabilities resulting fiom vitamin A and iodine deficiency - blindness,

deahess, and mental disability), infectious paediatric diseases (e.g., disabilities resulting from polio

and measles and which could be prevented by immunization programmes), and other infectious

diseases (e.g., disabilities resulting fiom tuberculosis and leprosy, as well as blindness and deahess

resulting fiom untreated eye and ear infections) (Cnsp, 1989; RVLMICEF, 199 1 ; Richman, 1995;

Werner, 1987, 1990b; UNICEF, 1990). Carbailo (1996) and Machel (1996) have also identified an

increase in the number of congenital disabilities attributable to inadequate prenatal care and

screening.

Impairment and disability are worscned by the absence or inadequacy of medical and

rehabilitation facilities, which are usually poorly developcd pnor to hostilities (UNICEF, 1990;

Zwi & Ugalde, 1991) and are ofien unavailable to refugees (Crisp, 1989). There are often delays

in accessing facilities, and in some cases admission to a rnedical facility may be avoided, for fear of

being exposed to arrea or capture (Al-Haq, 1988, 1989; Physicians for Human Rights, 1988). The

inability to travel to a hospital, or to attend rehabilitation programmes on a continuous basis,

worsens the prognosis for the original injury and leads to poor outcornes of treatment (Ballantyne,

1988).

2.4.2 Psvcho-social Trauma

It has been stated that "Psycho-social trauma is the most widespread effect of armed

conflict" (UNICEF, 1990, p. 194). Emotional, psychological and mental trauma which result

directly or indirectly from amed conflict are frequently profound and enduring (Bryce et al., 1989;

COPEDU, 1989; Eade & Williams, 1995, pp. 855-58; Garbarino et al., 199 1; Machel, 1996;

Richman, 1995; Schaller & Nightingale, 1992). Psychological disabilities rnay be relate. to king

the victim of atrocities, witnessing atrocities, feeling that death is imminent, being separated from

family and community, emotional distress comrnunicated through family members, expenencing the

destruction of the elements of normal lifc, or social rcjection as a rcsult of physical disability

(Gibson, 1989; RVUNICEF, 199 1; UNICEF, 1994). These long-lasting psychological effects have

implications for how victims, especially children, devdop attitudes, rclationships, moral values, and

a mental framcwork for undcrstanding life and society (Machel, 1996; UNICEF, 1990). There are

also implications for the possibility of future peaceful resolutions to the conflict (Physicians for

Human Rights, 1988; Rankin, 1991).

In any corn muni^ thçre is a population alrcady living with disabilities, oftcn less

recognized than the newly injured (Ballantyne, 1988; Godfiey & Kalache, 1989; Haramy, 1993;

Richman, 1995). Disability gained through fighting may bring honour (Atshan, 1997; Bruun,

1995; Salem, 1 WO), and esisting rehabiiitation is often gçared to adult men, especially combatants

(UNICEF, 1990). Nonctheless, in circurnstances of political violence, al1 disabled people suffer the

handicapping conditions of poverty, despair, inaccessible physical surroundings, infrastructure and

community breakdown, and facilities (which are oflen of marginal adequacy to begin with) being

taxd beyond the ability to cope (Physicians for Hum,m Rights, 1988; WHO, 198 i). In the context

of ecanomic stress, family breakdown and socid dislocation, disabled persons are also at greater

risk of domestic violence and child abuse (RI/LTNICEF, 199 1). They are increasingly dependent

upon others if it is necessary to flee conflict (Despouy, 1991 ; Richman, 1995). Howvever, negative

attitudes, cultural restrictions and ignorance may further disadvantage disabled women, children,

and the eiderly by leaving them bchind when the community is fleeing, and by puîting them lm in

line for food and medicine (Godfiey & Kalache 1989; RVUNICEF, 1991). Inability, or

unwillingness, to incur the costs of providing and replacing prostheses for growing children is a

cause of fûnher disability to child amputees (Machel, 1996; RUUNICEF, 199 1; UNICEF, 1990).

2.4.4 International Attention

The Gencva Conventions of 1949 addressed the issue of those disabled by war, but a new

concem for the plight of disabled children in arrned conflict was prornpted by the World Summit

for Children (Scptembcr 1990), and by an increased awareness of issues related to disability

emerging fiom the United Nations Decade of Disabled Persons (1 983 - 1992). In 1 Y 86, UNlCEF

became an outspoken advocate on this issue when it made "Children in Especially Dificult

Circumstances" a major focus (UNICEF, l!J86a, l986b, 1990). This included children who have

been physically and psychologically traurnatized by armed conflict or natural disasters. UNICEF

mobilized for the 1990 World Declaration on the SuMvaI, Protection and Development of

Children, which included a cornmitment by nations to:

... work to ameliorate the plight of millions of children who live under especially difficult circurnstances - as victims of apartheid and foreign occupation; orphans and street children and children of migrant workers; the displaced cfiildren and victims of natural and man-made disastcrs; the disabled and the abused, the socially disadvantaged and the exploited.

... work carefully to protcct childrcn from the scourge of war and to take mcasures to prevcnt fùrthçr armcd conflicts, in order to give children evcrywhere a peacefùl and secure future ... The essential needs of children and families must be protected even in times of war and in violence-ridden areas. We ask that pcriods of tranquillity and special rclief corridors be observed for the benefit of children, where war and violence are taking place. (UNICEF, 199 1, p. 56)

Days of Tranquility and Corridors of Peace were negotiated by UNICEF and other

agencies such as the international Cornmitter of the Red Cross, the WHO, appropriate ministries of

health, churches and non-govemmental organizations. These approaches were designed to allow

activities such as imrnunization programmes and the distribution of relief supplies during special

cease-fires, thereby demonstrating an overarching concem for the health of children. Such

strategies have been used successfully in El Salvador, Lebanon, Sudan and Iraq (Machel, 1996;

UNICEF, 1986b, 1990).

In November 1989, the United Nations (UN) General Assembly adopted the Convention on

the Rights of the Child (UN, 1989). In it, Amcle 23 asserts the nghts of mentally and physically

disabled children to dignity, active participation in the cornrnunity, and special care. Articles 38

and 39 outline the rights of children during armed conflicts, with respect to their recruitrnent and

protection, and the treatment of child victims. Building upon the Convention, in 1994 UNICEF

commissioned a study of "The Impact of Armed Conflict on Children," and its extensive report

specifically addrcssed the issues of landmines and disability (Machel, 1996). By 1996, UNICEF

had developed an explicit "anti-war agenda," which included a focus on relief and development

issues.

A special report of the United Nations Commission on Human Rights in 199 1 examineci

human rights and disability. This report recognized violations of hurnan rights and of humanitanan

law as factors causing disability, notcd the suRering inflicted on nonîombatants in situations of

armecl conflict or civil strife, and made particular mention of the situation of those with mental

disability (Despouy, 1991). Disabled Peoples' Intcrnational has pointed to the large nurnbcr of

disabilities tbat rcsult from illegal milita- operations, ill-treatrnent of prisoners of war, refusa1 to

attend to the wounded, and interference with the humanitarian action of civilians (citeâ in Despouy,

1991).

The United Nations High Commission for Refugees (UNHCR) has also addressed the

situation of disabled refugees (Crisp, 1989). In 1992, ü W C R published practical guidelines to be

usPd by their field officers, and others working with refugees, for prevention and treatrnent of

disabling conditions, as well as for rchabilitation (UNHCR, 1992). Areas of focus included

training, attitudes, suppon for disabled rehigees acting as leaders and workers, farnily support,

access and mobility, vocational training, education, and appropriate simplifieci rchabilitation

technology .

In 1989 the RVUNICEF Technical Support Programme conducted a review of the physical

rehabilitation needs of children and women victims of armed conflict, specifically in Angola,

Mozambique, El Salvador, Nicaragua, and arnong disabled Afghan refugees in Pakistan

(RXAJNICEF, 199 1). The report of this study identified how war causes disability, discussed the

magnitude of the problem, and directed attention to specific areas of concem (including needs for

accurate assessment, lack of tnined personnel, culturally-bascd concepts of disability, and equal

participation of disabled persons). Their recornmendations were aimcd towards generating

solutions; promoting cornmunity based rehabilitation, research and prevention, attention towards

women, children and mental disability, and the incorporation of disability issues into international

aid programmes for developmcnt and war and disaster relief.

Thus, various organizations have confronted the issue of disability under conditions of

political violence. nie Palestinian situation provides an example of rehabilitation issues bcing

addressed under circumstances of occupation and uprising.

2.5 The Palestinian Context

nie West Bank and the Gaza Strip are knowvn as the Occupied Temtories, or the Occupied

Palestinian Temtories. This refers to the areas bclonging to the pre-1948 British Mandate of

Palestine that were occupicd by Israel in 1967. Most recent population calculations identify almost

2.9 million Palestinians living in the Gaza Strip (30% of total population), the West Bank (60% of

total) a d East Jerusalem (10% of total) (Palestinian Central Bureau of Sbtistics, 1999; see dso

The Center for Poiicy Analysis on Palestine, 1992; FAFO, 1994).

2 S. 1 Political Violence

There is little doubt that Palestinians demonstrate a society living under conditions of

political violence. From ancient to modem times, the region has ben a place of regular invasion,

conquest and revolt. For Palestinians today, this century has been one of prolonged occupation - by Turkey until 1918, then by Britain until 1948, and then by Israel since 1948 (and, for sorne

Palestinians, by Jordan in the West Bank, and Egypt in the Gaza Strip, from 1948 to 1967) (for

chronology of events, see PASSIA, 1999). Those years of occupation also have been marked by

f u l l - d e regional wars in 1 948, 1956, 1967 and 1973. December 1987 marked the begiming of

the Pdestinian Uprising, called the Intifada (which in Arabic means "to shake off'). At the tirne of

this shidy, the 1993 Declaration of Principles had heralded "peace" between Palestinians and

Israelis, but despite the official end of the Intifada, occupation and resistance activitics continued.

Documentation of the character of Israeli occupation provided foreshadowing of future

troubles. Military administration and the establishment of Israeli settlements had broad negative

repercussions upon Palestinian persona1 status and rights, demographics, social nructurc,

ewnorny, education, and land ownership (Amri, 1983). Meron Benvenisti (1984) exmined West

Bank demography. economy, land use and owncnhip, legal and administrative concems, and Israeli

settlements, cntically analyzing the data in rems of lsraeii policy. Sara Roy's (1995) examination

of the political economy of the Gaza Strip also illuminated the role of lsracli policy and the grave

effects of occupation. Historical and political aspects of occupation provided the background for a

popular upnsing, as explained by Aronson (L990), as wll as The Center for Policy Analysis on

Palestine (1992), and the United Nations Cornmittee on the Exercise of the lnalienable Rights of the

Palestinian People (1 990).

During the Intifada, many organisations and the media reporteci upon lsracli human rights

violations in the Occupied Palestinian Temtories, but of note are two volumes published by the

West Bank affiliate of the International Commission of Jurists (Al-Haq, 1989, 1990). These

detailed violations related to the use of force, detentions, military justice, deportation,

aârninistrative methods of control, house dernolition, curfews, economic and fiscal sanctions, as

well as obstructions to medical care, education and wonhip, repression of organizational activity,

and actions towards women, human rights monitors, and the media. Further research and analysis

of the above issues, as well studies of non-violent civil raistance, and international, Israeli and

socio-histoncal implications of the uprising, were documentai by Hiltemann ( 199 1 ), Lockman and

Bcinin (1989), Nasser and Heacock (I991), and Peretz (1990). Garbarino et al. (1991) and Gibson

(1989) examined the violence with emphasis on the cxperience of Palcstinian children.

b can be seen that occupation and uprising affected vimially every element of Palestinian

life. It was inevitable thût health and disability would also expenence the impact of the conditions

of political violcnce.

2.5.2 Effects on Health

in their evaluation of thc impact of political violence upon public hcalth, Zwi and Ugalde

(1991) use the Palestinian Intifada to illustrate "teactive political violcnce". Initially, Palestinian

hcalth suffered as a result of restrictions by the militan, authorities on hçalth development

(Association of Israeli and Palestinian Physicians for Human Righrs [AIPPHR], 1990; Giacaman,

1984; Smith, 1987; Union of Palestinian Medical Rclicf Cornmittees [UPMRC], 1987). Early in

the intifda, the nature and extent of violence directly causing death and injury were investigated

and were welldocumented by Nison (1990), the international Commission of Jurists (Al-Haq

1989, 1990), and Physicians for Human Rights (1988). The indirect impacts on health of

occupation and uprising resulted pnmarily from dismpted immunization and prenatal health

programmes, curtailed food, water and sanitaiy service provision, and restricted or obstnicted

medical care (AIPPHFt, 1990; Al-Haq, 1989, 1990; Barghouthi & Giacaman, 1990, 199 1 ;

Bellisari, 199 1; Physicians for Human Rights, 1988; Rigby, 199 1 ; UPMRC, 1988).

2.5.3 Effects on Disabilitv

Studies of disability in the Occupied Palestinian Tcmtones have revealed a prevalence of

b e ~ n 2 % and 4.5% of the population (Brauelli, 1995; Central National Cornmittee for

Rehabilitation [CNCRJ, 1992; Giafaman, 1991, 1993; Giacaman & Haramy, 1996; Haramy et al.,

1 995; Jarrar & Giacarnan, 1 994), with a most recent national figure of 1.9% (Palestinian Central

Bureau of Statistics, 1997). Nonetheless, nearing the end of the Intifada, the CNCR (1992)

estimateci that 100,000 had been injured by violence, and 1,500 had bcen Icft wiîb permanent

disabilities requiring assistance.

The phenornenon of the Intifada-injured had a significant effect upon Palestinian attitudes

towards disability, introducing the notion of honorific injury, (Atshan, 1997; Mash'al, 1 990).

Mouna Odeh Salem (1 990) examined this intensively, drawing parallels with the Nicaraman,

Eritrean, and South Afncan Apartheid experience. This important change in attitudes gave new

energy to the Palestinian disability movcment (MacGrory, 1996; Salem, 1992) and prompted a

critique of the status of the human rights of Palcstinian persons with disabilities undcr Israeli

occupation (Gaff, 1994).

Early in the Intifada, Palcstinian rehabilitation efforts wcre largely understood and

fashioned in tems of physiothcrapy, although community care was oAen ernphasired (Ballantyne,

1988; Khamis, 1992-93; Krammer, 1990; Vandam, 1989; Verhoeff, 1989). By thc 1 WOs,

however, CBR had become the preferred approach for addressing disability, endorsed by the

CNCR and the United Nations Relief and Works Agency for Palestinian Refugees (UNRWA)

(CNCR, 1992; Coleridge, 1993, chap. 1 1; Forsby, 1995; Giacaman, 1993; Giacaman & Haramy,

1996; Haramy, 1993; Haramy et al., 1995; Jarrar & Giacarnan, 1994; Mendis, 1996; UNRWA,

1992). In their West Bank Rural Prirnary Heaith Care Survey, Barghouthi and Daibes (1993, pp.

324-25) documentcd three organizations providing CBR services, with the Union of Palcstinian

Medical Relief Cornmittees (UPMRC) CBR programme being the most extensive. The UPMRC

h;td undertaken to transfomi its physiotherapy services into a regional CBR programme (Mash'al,

1991, 1993; UPMRC, 1994).

Due to the crisis of the Intifda, CBR had been proposai as a means of addressing the

rehabilitation needs which ovenvheirned available seMces for people with disabilities (Giacaman &

Daibes, 1989). In 1990, however, Mouna Salem asked the question: "how effective will CBR be,

given the constraints in movement imposed by curfews, roadblocks, lack of sense of security, etc?"

@p. 89-90). The current study sought to answer such a question, by allowing the UPMRC CBR

programme partici pane to reflect u pon their experience under occupation and Intifada.

2.6 Relief and Development

Palestinian CBR was initially envisioned as non-govemmental organizations providing

assistance for people with disabilities (CNCR, 1992). Within the 1990s, however, there has been a

cntical re-thinking of how relief assistance should be provided to people sufiering under conflict

conditions (Adams & Bradbury, 1995; Anderson, 1993, 1994b, 1995; Bush, 1996; Commins,

1996; Eade & Williams, 1995; Minear & Weiss, 1993; Mooney, 1995; Weiss & Minear, 1993).

Belief that negative effects of relief interventions should be avoided, and that principles of

development should not be abandoncd, has led to the perspective which advocates greater balance

and less distinction between relief and development efforts. Non-governmental orpizations are

key acton in codict situations, and:

"the experiences of NGOs operating in such situations can provide a valuable base for helping other agencies to identiw development potential within confiict, to review their priorities and capacity for work in different settings, and to present policy challenges to governments and donors. Without an understanding of the ways in which development can and does occur in the midst of conflicts, NGOs will miss opporhmities to strengthen local communities." (Comrnins, 1996, p.8)

In discussions of relief and development, the work of Mary Anderson and Peter Woodrow

is widely cited and used to understand and promote community development in the context of

conflict and natutal disaster (see above works, also von Kotze & Holloway, 1996). Anderson and

Woodrow (1989) assert that any assistance made to communities living in conflict must not simply

provide relief, but must contribute to long-term development. In order to be developmentai, an

agency must recognim existing community capacities and wlnerabilities, and the assistance

provideci must strengthen capacities and d u c e vulnerabilities. To maximire benefits, and to avoid

negative impacts, agencies are encourageci to assess their target beneficiaiy communities according

to a framework callcd the Capacities and Vulnerabilities Analysis (CVA). Using the CVA

framework leads to an appreciation of community capacities and vulnerabilities in three rcalms:

physical/material, sociaVorganizational and attitudinai/motivational (see Appendix 1.). The CVA

can then be used for planning, implementing, and evaluating interventions in emergency conditions.

Anderson and Woodrow's CVA approach is straightfonvard, and is philosophically

attractive in that it shares CBR's focus on ability versus disability, of independence and

interdependence rather thm dependence, and of "participants" as opposed to "victirns." These

factors are in contrast with another possible theoretical framework for "sociological analysis of

collcctive stress situations" (Barton, 1969), which involves analyzing 69 complex interactive

eiements within a "therapeutic community response" (pp. 274-75). Therefore, Anderson and

Woodrow's Capacities and Vulnerabilities Analysis approach ww chosen to aid data analysis in

the WMRC case, because of its wide applicability in international settings, and its rclevance to

CBR.

CHAPTER 3

METHODOLOGY

3.1 Research Design and Rationale

The design of this research is a single qualitative case study. The unit of analysis is the

CBR programme of the Union of Palestinian Medical Relief Cornittees. A case study was chosen

because it i s a study which " investigates a conternporary phenornenon within its real-life context,

when the boundaries bctween phenornenon and context are not clearly evidcnt, and in which

multiple sources of evidence are us# (Yin, 1984; p. 23). Michael Patton (1990) notes that a

qualitative case study is "usefùl where one necds to understand some special people, particular

problem, or unique situation in great dcpth" (p. 54). The intent is to describe, reveal, and provide

an interpretive approach to understanding the meaning of expcricnces (Manhall & Rossman, 1989;

Tesch, 1990), by investigating a case that is "information rich" (Patton, 1990, p. 169; sçe also

Gilgun, 1994).

For qualitative case studies, Robert Stake differentiates between intrinsic case studics, in

which the importance of the Case is emphasized, and instrumental case studies, in which the

importance of the Issues is emphasized (Stake, 1995). In the current research, the case is the

UPMRC CBR programme, but the ei&t CBR elements (previously descnbed) have been uscd to

create the conceptuai framework for the issues under study. Thus, the study is instrumental, since

it follows Stake's recommendation whcn he notes "1 choose to use issues as conceptual structure - and issue questions as rny primary research questions -- in order to force attention to complexity

and contextuality" (Stake, 1995; p. 16).

A qualitative approach is therefore appropnate for the current study. Methods of analysis

have been established (Miles & Hubeman, 1984), and the rigour of the approach is accepte.

within rehabilitation therapy research (Jcnson, 1989; Krefiing, 199 1).

3.2 Location

The research took place in the Occupied Palestinian Temtories. West Bank locations

included the villages of Biddu, Aboud, Zabebdeh, and Ithna, the cities of Qalqilya, RamaIlah, and

Nablus, and the Jenisalem office of UPMRC. InteMews were also conducted in the Palestinian

Self-Rule areas of Icricho (in the West Bank) and within the Gaza Strip. Thcse representcd places

where UPMRC CBR programmes operatcd, or central meeting places for respondents. InteMews

were conducted in clinics, offices? and homes, according to respondents' preference and feasibility

for travel.

3.3 Data Collection

Data collection began September 12, 1994, and was concluded December 16, 1994. Data

was collccted by: 1) revicw of documents, 2) scmi-stnicturcd inteniews, 3) focus group

discussion, and 4) observation of rehabilitation activities and facilities.

Documents rcviewed includcd dozens of UPMRC CBR programme rcports, meeting

minutes, training curricula and activity schedules. In addition, the Palestinian public research

organiration, the Hcalth Dcvelopmcnt Information Project (HDIP), provided the researcher with al1

documents related to Palestinian disability and rehabilitation (approxirnately 18 publications), from

their comprchensive inventory. Documents in Arabic were translateci by cornpetent independent

translators. Documents (and interviews) provided information regarding the UPMRC CBR

programme history, structure, panicipants, activities, and strategies, as well as information about

the development of other Palestinian rchabilitation initiatives.

Therc were 18 in-depth interviews, each lastins approxirnately one to two hours. Most

were held with individuals, although on three occasions interviews were held with two respondents,

who indicated a prcference to be interviewed togethçr with their project team partners. Arabic /

English interpretation was required for three interviews, and \vas provided by colleûgues of the

respondents. Prior to conducting the indepth interviews, a pilot i n t e ~ e w was conducted with an

English-speaking CBR worker who had recently finished working with UPMRC. (The pilot

i n t e ~ e w was not subjected to analysis, nor included in study results.) As a result ofthe pilot

interview, the researcher appreciated the dual nature of political violence, and addressed both

Occupation and Intifada in upcoming interviews. Before bcgiming interviews, the researcher

consulted with UPMRC CBR managers regarding the suitabiiity of English terms to be used, and

some refinements were made (e.g., not using the word "collaboration" for cooperation arnong

organizations, as this term had negative political connotations). Similarly, afler the i n t e ~ e w s the

researcher sought clarification from local resource people regarding the meaning of certain Arabic

terms used.

During the intervicwvs, the researcher posed questions that correspondcd to the previously

identifid list of eight CBR elements (see Appendix II. for interview guidc). Respondcnts were

asked for their perspectives on whether and how the CBR elements were affected by conditions of

Occupation and Uprising, and how the UPMRC programme addressed each CBR elemcnt.

InteMews were audiotapcd (exccpt in two cases, at the request of those respondents), and notes

were taken during interviews. Aftenvards, the rescarcher transcribed tapes and notes.

There were 2 1 interview respondents, chosen as key infamants with guidance fiom the

actingdirector of UPMRC. A description of the respondents is seen in Table 3.1, with their

criteria for selection. There were fiftecn women and six men. One of the respondents was both a

CBR worker and a person with a disability.

AAer interviews were completed, one focus group discussion was held witb ten CBR

workers and one CBR manager. (The CBR manager and seven of the CBR workers had been

previously intervieweci.) The discussion vas organized for the convenierxe of workers attending a

regular weekly programme meeting, and was chaired by the rescarcher. During this discussion,

participants clarified and expanded upon earlier interview responses regarding their wvorking

environment. Specifically, they listed: the obstacles resulting from Occupation and Intifada that

they encountered on a day-to-day basis, the responses they made to each problem, and the positive

aspects of work under those conditions. Audiotape of the session was of poor quality, but notes

were taken on a flip-chait by the researcher during the discussion.

Table 3.1 Description o f Interview Respondents

Respondent category Number Reason for inclusion

Nine rehabilitation workers and four physiotherapists.

13 (Chosen fiom a total of 19 CBR workers, on thc basis of CBR workers lcngth and extent of their expericnce within the

I programme. Twelve women, one man.) l The UPMRC staff responsible for CBR programme

CBR managers 2 management. (UPMRC acting-director and CBR programme manager. Two men.)

Non-LJPMRC Palestinian CBR experts. (Chosen on the basis of their key roles in CBR developmcnt in the West

CBR advisors 3 Bank and in Gaza - two CBR p r o g r m e managers, one Community HealthKBR consultant. Two women, one man.)

From CBR programme participants, rehabilitation 1 PeopQ wiîh dirabilitier 4 workcrs, and the General Union of Palestinian Disabled. 1 (One woman, thrce mm.) I

Observation of rehabilitation propmrne activities and facilities, involving travel to the six

regional projects in the West Bank, providcd the researcher \rith context for interview data. The

researcher took the opportunity to accompany CBR workers at weekly team meetings and dunng

home visits, and to observe CBR activities at day care centres and clinics.

Additional interviews were held with representatives of rchabilitation institutions, of other

CBR programmes, and of international NGO supporters of CBR. These meetings took place in

Jerusalem, Ramallah, Birzeit, and Gaza. The discussions provided information on the broder

context of Palestinian CBR and wu also used to triangulate data received from UPMRC.

3.4 Analysis

Organization of data was facilitated by the ETHNO cornputer sofhvare (Tesch, 1990, pp

2 1 10222)~ and analysis proceeded with manual coding ( s e Miles & Hubenan, 1984, for

qualitative &ta analysis procedure followed). With a theoretical framework based upon the eight

elements of CBR, first level codes were initially fonnulated to refiect these elements, as well as the

experiences of political violence and CBR program activities. As transcribed data was coded, these

initial categories were supplemented and refined. Descriptive codes came to include contexhial

factors, such as culture.

During the second level of coding, or pattern coding, themes were developcd. For example,

individual expericnces of political violence (such as curfews, or the Intifada-injured) were grouped

into larger 'conditions,' and then differentiated into hvo major types (Occupation and Uprising).

Initially, while considering how elements were affected by conditions of political violence, a theme

of chonge ernerged. The data indicated that the role of the CBR workers \vas to create change,

specifically within the categories of the CBR elernents. With this therne as the orgmizing principle,

data was coded for barriers to change, strategies for change, and actions for change, related to

each element. Individual and community leveis of change were identifid. nie concept of change

was also attractive since UPMRC felt the purpose of CBR was not to develop a thing (a service),

so much as to affect a process. In addition, thc CBR programme had undergone significant

transfonation within a context of ongoing political and social change. Howvever, as change could

mean either improvement or detenoration, it became apparent that the themc of positive change, or

development, was more accu rate.

Simple diagranming of the sequence of conditions, elements and responses was made (see

Appendix III for data analysis tools) and the codes for a descriptive case were elaborated. A

sarnple of the code list is also found in Appendix III. Codes identified:

- the conditions of political violence,

- effects of the conditions upon the general work environment of the CBR workers,

- effects of the conditions upon each of the CBR elernents,

- the responses made to these effects,

- other influences, of the Palestinian context, upon the CBR elements.

Data was organired in files according to codes. These files were examined to assess the

content, fiequency, and weight of responses in each category. A consensus of opinion among

respondents became apparent at this time, and is rcflected in reporting of results. Using a series of

matrices to display the s u ~ a r k d data, important conditions, elernents and processes also became

evidcnt (see Appcndix III for an example of matrices created durhg analysis process).

At the next level of analysis, memoing was uscd to explore conceptual intcrprctations of

the findings. Explanations for the findings used the lens of community development to describe

CBR under conditions of political violence. The analysis drew upon a theoretical mode1 for

community devcloprnent that addresses the issue of providing assistance to communities in time of

crisis (Anderson & Woodrow, 1989). The concept of community development was consistent with

the philosophy of the CBR programme and UPMRC. The Anderson and Woodrow approach was

used to reflect upon the responses that the CBR programme made to conditions of Occupation and

Uprising.

3.5 Establishing Trustworthiness

Reliability and validity are tequisites that have been intçrpreted into the qualitative research

context, and as such they have been applied specifically to rehabilitation therapy research (Jenson

1989; Krefting, 199 1). Guba translates the concepts of reliability and validity into trustworthiness

(Krefiing, 1991). Using Guba's criteria of crcdibility, transferability, dependability and

confinnability, Krefting outlines procedures for establishing trustworthiness, and those methods

used for this case study research are as follows:

1. Credibility (tnith value)

'The researcher engaged with respondents, for three months during data collection and two

years during analysis and writing. Data collection methods and data sources were triangulated,

such that remarks that were challenged by other respondents (Le., in the focus group discussion) or

isolated remarks which were not supporied were not included in .he findings. IntcMew techniques

were consistent. (In addition, recognizing that English was not the first language of respondents,

the researcher used familiar English tcrms and simple language when necessary, whilc accuracy

was aided by the researcher havins adequate understanding of the Arabic uscd during translation.)

Processes, categories, interpretations and conclusions were checkcd by participants and peen.

Field joumaling aided self-rcflection.

2. Transfcrability (applicability)

An indcpth description of the case is provided for the reader.

3. Depcndability (consistcncy)

An indepth description of research methods is provided. Data collection mcthods and data

sources were triangulatcd. First- and second-lcvel coding wcre done by the researcher, and re-

coded to confirm categories after a p e n d of one to two months. Coding of two sample interviews

by an outside researcher also confimed the categories. The analysis process was under academic

supervision.

4. Confirmability (neutrality of data)

Triangulation of &ta collection mcthoàs and data sources was followved. Self-reflection

was continuous, and was aided by field joumaling. The research process was under academic

supervision.

3.6 Ethics

From Canada, entry to UPMRC was gained by written request made to the organization,

with submission of the research proposai, which included ethics approval from Queen's University.

In Jerusalem, both the researcher and the study were introduced to CBR workers by the UPMRC

CBR programme manager. Participation in the saidy was voluntary.

informeû consent to participate in the study was obtained from interview respondents, with

each respondent choosing to sign either the English or the Arabic fonn (see Appendix N. for

sample fom). The Arabic form was translated by the UPMRC translater, and accuracy was

confirmed by translation back into English by an independent resource person. At the outset o f

&ta collection, the UPMRC acting-director advised the researcher that the potential for a security

risk to participants, (resulting from exposure of their activities dunng politically-sensitive times)

had been eliminated by the changed political situation and peace initiatives of that time. There were

no refûsals to be intervicwed, atthough two respondents agrecd only on the condition of not bcing

audiotaped, due to their discornfort with that process.

Data was collected and analyçd by the researcher and maintained in confidcntiality.

Audiotaped conversations and field notes were transcribcd directly ont0 cornputer, and tapes and

transcripts were kept in securc storage during transcription and analysis. Transcripts were d e d

for the interviewee's name, and the master file of narnes and codes kcpt in a secure, separate

location. Tapes were then erased.

The researcher \vas required to e.uhibit sensitivity to the cross-cultural element of the

research. Previous expenence of living and working in the region, ongoing consultation with local

people, and common sense were her guide to rnaintaining appropriate behaviour.

CHAPTER 4

RESULTS

In this chapter, the results of data collection are presented. At the outset, thcre is a

description of the UPMRC CBR programme. Following this, the programme is further

contextualized by presenting factors that were noted to affect CBR in Palestine.

This background material is followed by a description of political violence and CBR. The

conditions of political violence of this case are outlined. Following this, there is a description of

how the conflict conditions specifically affccted the CBR workers of UPMRC in the day-to-day

performance oftheir duties. The remainder of the chapter is then devoted to assessing the impact

of the Israeli Occupation and Palestinian Uprising on CBR. In this assessment, the eight elements

of CBR are presented individually. For each one, there is a brief explanation of how the element

was demonstrated within this w e . This explanation is followed by a discussion of how the conflict

conditions affectai that element, and CBR programme responses. The presentation of results is

concluded with a final surnmary.

4.1 Description of the CBR Programme of UPMRC

Data for the following case description was obtained through document review and

discussions with CBR managers and advisors.

4.1.1 Evolution of CBR within UPMRC

The Union of Palestinian Medical Relief Cornmittees was established in 1979, in response

to inadequate health seMces provideci to Palesthians by Israeli authorities. At that tirne,

Palestinian physicians of UPMRC began offering primary health care services on a voluntary bais

to remote and unseniced areas in the West Bank and Gaza Stnp. Subsequently, village health

workers were trained, and medical, dental and laboratory services wre expanded. The

infrastnicture that underlay these widcspread health activities was covert, because these were ipso

facto in resistance to military rule. In 1986, prompte. by the unavailability of rchabilitation

seMces to people with disabilities in the rural areas, a physiotherapy component was incorporateci

into the medical services. The focus on rehabilitation was soon reinforced by the emergence of the

Intifada, which bcgan in 1987, since the high number of injuries increascd need for services and

raised the profile of disability in Palestine.

Thc physiotherapy programme of UPMRC evolved into CBR over the pars that followed.

Onginally, physiotherapy scnices were provided in selected regions. Therapists from Europe and

Canada were recruited and supported by international development NGOs. Village hcaltb workcrs

(VHWs) informally assisted the physiotherapists. Shortly thcreafter, UPMRC incorporated a

formal rchabilitation component into the VHW training. By 1990, UPMRC had adoptcd a CBR

philosophy, this being consistent with its primary health care focus and the community mobilization

of the Intifada. As the Intifada continucd through the early 1990s, transition to CBR occurred

within each physiotherapy project arca according to its oun regional chanctcristics and resources.

Most of the CBR projccts flourishcd, wvith rchabilitation workers trained and CBR teams created

for rehabilitation service dclivery and community development that addrcsscd disability.

CBR was explicitly endorsed by UPMRC and other NGOs in the Occupied Temtories.

International CBR activists, such as Einar Helander and David Werner, wçre invited to the region,

and their visiîs further promoted the CBR approach.

4.1.2 CBR in Palestine

With other rehabilitation providers and consumes, UPM RC was instmmcntal in forming

the Central National Conuniîîee for Rehabilitation (CNCR) in 1989, and integrating CBR into that

body's mandate. The aim of the CNCR \vas to build a comprehensive Palestinian rehabilitation

system. It was a forum of both institutional and cornrnunity organizations, and was particularly

important because under the Israeli military administration there existed no government support for

such programmes. Through the CNCR, rehabilitation activities were cmrdinated on a regional

basis. The four regions were the North, South and Central West Bank, and Gaza (with its own

Gaza National Cornmittee for Rehabilitation).

Community based rehabilitation programmes were implemented according to this regional

plan. Various NGOs took responsibility for CBR in each region, dcpending upon the organizations'

presence and previous activities. The NGOs that implemented CBR were local hcalth and

development organizations (such as the Red Crescnt Society and UPMRC), as well as Christian

and Islamic organizations and charitable societies. In this way, WMRC took a icading role in the

devclopmcnt of CBR in Palestine.

4.1.3 Thc UPMRC Programme

4.1.3.1 Organization and covcrage

Thc full orgmization of UPMRC constituted one of the largest Palestinian health NGOs,

working in all regions of the Occupied Temtories. lu pnmary h d t h a r c (PHC) componcnt

involved 28 community hcaith centres, with over 200 staff and 1000 volunteers. Its CBR

component was srnalier, but was nonetheless the most extensive Palestinian CBR programme. It

was active in 77 towvns and villages in the West Bank, representing a population of 200,000 people.

The position of CBR wvithin the UPMRC organization is indicatcd in Figure 4.1.

Figure 4.1 The Position of CBR within the UPMRC Organization

HK=

The CBR Programme was implemented through six regional project tcams. The catchent

area of these tearns is shown in Figure 4.2. This figure also illustrates the ho-part nature of the

Jenin project .

- i

I

, CBR

.

Qalqiliy

Biddu d Jericho

O Bethlehem

Figure 4.2 Map of the West Bank, Showing Catchment Areas of CBR Projects (shaded)

nie programme catchent area was extensive, though not al1 of the project areas had

undergone a disability survey, and therefore coverage Mas not cornprehensive. The number of

villages per project is shown in Table 4.1.

Table 4.1 Regional Catchment of CBR Tearns

1 Regional team Number of villages I 1 Biddu 9

Qalqilya 8

4.1.3.2 Participants and Linkages

The UPMRC CBR programme cooperated with Palestinian NGOs through CNCR, but it

also had other important links and pamerships. These are shown in Figure 4.3, and descnbed

below.

Figure 4.3 Participants and Linkages

b

r UPMRC - PHC

International md physiotherapy Speciaiists and partners institutions

Central National . Committee for

Rehabilitation

UPMRC Health care providers participated in the CBR programme through the

organization's PHC structures and personnel. Referrals were made through UPMRC

Peopk with disabili ties

village health workcrs, nurses, fmily doctors and specialists. The CBR programme was

also complemented by two UPMRC specialired physiotherapy clinics, each of which acted

as a referral centre. In Nablus, the UPMRC physiotherapy clinic initiated CBR work in

cooperation with the Palestinian Red Crescent Society, while in Gaza the physiotherapy

clinic cooperated with the CBR programme of the Gaza National Cornmittee for

Rebabilitation.

Institutions and outside specialists cooperated with the CBR programme, providing

medical, surgical and rehabilitation services.

Academic support

Academic support was provided by Birzeit University's Community Heath Unit, which

assistai the CBR programme with policy, planning, education, and research. Research and

logistical support Hpre dso provided by the Health Development tnfomation Project.

People with disabilities provided advice to the CBR programme and were represented

arnong the rehabilitation workers. The General Union of Palesthian Disabled (GUPD)

was supported in its formation by the UPMRC CBR programme, and maintained a close

relationship with UPMRC. UPMRC was instrumental in gaining forma1 representation for

the GUPD on the CNCR.

Community input to the CBR programme was characteristic of each project region

Regions differed in several characteristics (to be described later), and thus the degree and

nature of comniunity involvernent varied. In some cases, formal involvement occurred

through local heal th or rehabilitation committees, or other structures such as women's

committees. Community resources were also offered by merchants, teachcrs, craftspeople,

vocational training facilities, and conununi ty activists.

Partnerships were developed with international development NGOs, which provided

ongoing financial, persorinel, educational and moral support to the CBR programme.

These NGOs included the Organisation Canadienne pour la Solidarité et le Developpement,

Diakonia (Sweden), Gmppo Volontariato Civile (My), Nomsme (Noway), and the Third

World Relief Fund (Belgiurn). International governments and developmcnt NGOs were

the primary sources of funding for UPMRC's programmes.

4.1.3.3 Personnel

The Executive Cornmittee of UPMRC provided administrative direction to al1 programmes

within the organization, including CBR. The six CBR teams w r e supervised by the CBR

Programme Manager. This organizational structure of the CBR programme is shown in Figure 4.4

UPMRC Executive Cornmittee m ( CBR Programme Manager 1

Figure 4.4 Structure of the CBR Programme

At the time of this snidy, each of the reejonal CBR projects had a team of CBR workers,

compriscd of one physiothcrapist and a varying numbcr of rehabilitation workers. Nationality and

educational characteristics of thcse personnel are outlincd in Table 4.2. There werc 30 Palestinian

CBR workers, and 3 foreigners. The CBR worken were mostly women, and Uicluded people with

disabilities. While the physiotherapists were not from the regions in which thcy wvorked (with the

exception of one), the rehabilitation workcrs wcre local to their projects. Thc rchabilitation

workers had various backgrounds, including village health and social work. Thcy had undergone

their CBR training within a cooperative training programme with rchabilitation workers of other

NGOs.

Jericho T m

. Jenin Team

Qalqilya Biddu Team

Aboud Nablus J Team A Tearn J . Team

Table 4.2 Characteristics of UPMRC CBR Workers

1 Type of CBR worker 1

Training

NationaMy

University degree in Training through Swedish NGO Diakonia, physiotherapy7 foreign and local universities, using adapted WHO universities or Bethlehem rnaterials. (Cornrnunity development input University (three with UPMRC from UPMRC) scholarships)

Physiotherapists Rehabilitation workers (RWs) . 1

Palestinian and European Paiestinian

4.1.3.4 Programme Activities

CBR activities were carried out through home Msits, community programmes and resource

centre activities. In addition, the teams met weekly in a central location, together with the

Programme Manager, to share experiences, problerns and ideas, and to discuss plans. Table 4.3.

shows programme components in t e m of activities and with thcir main contributors.

Table 4.3 CBR Programme Activities - -

Location Act ivi t ies Contributors

ActiMties of Daily Living skills RWs, family membcrs, Home visits Social integration physiotherapists

Environment adaptations (e.g. home, school, workplace) RWs, physiotherapists, community

Cornrnunity Public and school education members, programme volunteers Media promotion Recreation activities

Day Care Centre: play groups, pre- RWs, children, family members, school education, mothers' meetings programme volunteers,

Resourcc: physiotherapists Centre

Physiotherapy: assessment, trament, Physiotherapists, people seeking referral consultation

4.1.4 Surnmary

In surnmary, the CBR programme of UPMRC evolved out of a primary health care NGO,

and this comrnunity health link remained strong. in addition, the programme was implemented with

the participation of several other secton of Palestinian society. UPMRC actively pursued a

national plan for rehabilitation in cooperation with other NGOs.

Funding for UPMRC operations was provided by international partners, but the

organization was proactiveiy reducing its reliance upon foreign physiotherapists. A combination of

professional and non-professional personnel promoted a community development mode1 for

disability.

Adoption of a communiîy developrnent philosophy 'nad caused the CBR programme to

mdie CBR training based upon the WHO rnodel. At the sarne time, CBR irnplementation

necessarily took into consideration the context of Arab culture, Palestinian regionai characteristics,

and local perceptions and approaches to disability .

4.2 Contextual Factors Affecting CBR in Palestine

There were several contextual factors that affcctçd CBR, in addition to those of political

violence. These were the factors of Palestinian culture, regional and community charactenstics,

professionalization and institutional ization of disability, and attitudes towards disabled people.

4.2.1 Palestinian Culture - Support and Authorih,

Respondents described Palestinian comunities as behg formed of "strong families,"

meaning that they were close-knit, with supportive, extended family structures. The strength of

fmily ties was considered to be a positive factor for CBR. At the same tirne, the traditional large

family size posed a challenge. Mothers were the primary caregivers, and they typically cared for

many children. Ttiis left them with limited resources of time, energy and money to devote to the

ne& of a farnily member with a disability.

Traditional Arab culture also maintained clear and separate roles for women and men, and

this was very apparent in villages. The rehabilitation workers (RWs) were mostly women, and werc

respected comrnunity members, which hcilitated home visiting to mothers and childrcn.

Nonetheless, the RWs occasionally faced censure from men in traditional homes. It was not

unusual for husbands to restrict the activities of their wives outside the family, and some feared that

the relationships developed between their wives and the RWs represented an undesirable outside

influence. A CBR worker described one husband's concems, saying, "he didn't want her to be opçn

on the life." Social segregation also influenced CBR such that public meetings on programme

issues were sometimes held separately for women and men.

Shared cultural values and religious beiiefs encouraged Palestinians to "hclp the disabled."

However, this widespread charitable approach was identifiai by respondcnts as undcnnining the

strength of people with disabilities. (This will be discusscd below, specifically considering aîtitudes

to disability). Family eldcrs sometimes took responsibility for making decisions about members

who were disabled, seeking help from respected local community leaders such as the sheikh of the

mosque, or taking the person to traditional healçn. In this context, CBR workers providd public

disability education that addressed the local traditionai practices and belicfs.

Respondents frcquently described Palesthian socicty as "hierarchical and authoritarian,"

and explained that this influenccû working relationships. A CBR worker larnented. "we are a

wmrnunity that you can't function unless you have somebody supervising you." It was noted that

efforts to work democratically in CBR occurred within a swiety that was neither egalitarian nor

democratic. It \vas also said that risid upbringing and schooling practices impeded creativity, by

discouraging expression and innovation among children. A CBR manager said that this negatively

afEected CBR, explaining, for esample, that "appropriate technology is dependent upon creativity."

Finally, respondents pointcd out that the philosophy of CBR implied working for change,

and change usually occurred slo~vly. A CBR worker, reflecting upon integration of people with

disabilities, comrnented, "we are a conservative socieîy, h t m a s it's very hard to bring social

change, on any level."

4.2.2 Reaional and Cornmunitv Characteristics - Geo-political and Econom tc Disparities

It was apparent that communities varied across the country, and respondents noted that

elements of CBR were strongly infl uenced by regional characteristics. ïhe main differences were

describeci between the regions of the North, South, and Central West Bank, and Gaza. and

differences were also mentioned between rural, urban and refigee camp settings. Ar; a CBR

worker reflected, "even we are one Palestinian society, but there arc small socicties within."

Within Palestine thcre were rcgional disparities of wealth and institutional resources for

disability. The Central region, with the cities of Jerusalem, Ramallah and Bethlehem, \vas notably

richer in econornic resources. With the advanbge of more rehabilitation services, integration for

people with disabilities was often easier in those cities.

Historical and geographical differences were also evident within CBR. Previous

govemment administration of Gaza (by Egypt) and the West Bank (by Jordan) was said to have

influenced their CBR programmes, in that the hvo Occupied Temtories had dinering concepts and

methods of administration and bureaucracy. Diffenng regional concentrations of refugee

populations also influenced community needs and CBR methods. This stemmed fiom refugee

camps representing politicizcd and organized groups, with their own mechanisms for receiving

health seMces from the United Nations. Finally, geographical differences were relevant to

accessibility and integration, as a CBR worker illustrated when commenting upon the challenges

posed to wheelchair users by the mountains of Nablus and the rough terrain of villages.

Communities differed rnarkedly in their degree of isolation, their scnse of cohesion, and

their leaden and activists for disability. A CBR worker provided an example of one town,

characterized by its few but very strong families, in which people al1 h e w one another and this was

reflected in supportive community participation in the CBR programme. In contrat, another

village made a CBR worker welcome only after years of slowly gaining trust through unobtrusive

home visits.

It is relevant to note that the factor of regional difference is not cornpletely independent of

the conditions of political violence. Palestinians shared similar expcnences of Occupation, but the

violence of the Intifada differed in nature and seventy across different regions and comrnunities.

Nablus, for example, was considered "hottcr" than Jcricho, in terms of violent resistance and the

number and profile of Intifada-injured. Accordingly, respondents in Jericho noted that attitudes

towards disability werc not changcd radically during the Intifada, as they had been in Nablus.

4.2.3 Professionalization and lnstitctionalization of Disabilitv - Privile- of Ex~crtise

Palestinian efforts to develop CBR took place against a backdrop of a medical mode1 of

disability, emphasizing services providcd by professionals and institutions. Mcdical professionals

were considered the cxpcrts and, uritil recently, the spokespersons for disability. A CBR manager

commenteci that disability had been "an able-bodied type of business." Families sought curative or

residential institutional care, and ofien expressed reluctance when first approached to engage in

CBR, being unconvinced that they should perforrn what they believed to be the role of a health

professional. At the s m e tirne, there were very few occupational therapists, speech therapists, or

special education teachers. Therefore there was reliance upon doctors, and upon a growing number

of physiotherapists .

The institutions and 'sheltcrs' for people with disabilities were frequently described as being

of exceptionally poor quality - lacking skilled staff', with "conditions like a prison," fostering low

levels of self-esteem and ambition among residents. Despite this, introducing the CBR approach

was still a challenge, since a change fiom reliance upon professional care was interpreted as a great

nsk. Indeed, a CBR manager confirmed that CBR was an innovation, and that UPMRC was

building a new and alternative mode1 for rehabilitation.

4.2.4 Attitudes Towards Peo~lc with Disabilities - Tradition and Charity

Respondents described attitudes (or "the mentality") towards disability that were generally

negative; feelings of shame, pity, and even hopelessness. The very descriptive Arabic word

"haraam" was fiequently used regarding people with disabilities. "Haraarn" invokes a great pity

and sadness towards a hclpless person - "Haraam, pity, pwr person, you have a disability, you

can't do anything." As one CBR workcr explained, "Our people, they ignore the disabled people.

They donPt take care of thcm. They don? think that they have needs like others. They don't like to

confess that they have disabled people. They feel asharncd from k m . "

Respondents noted that such feelings arose primariiy fiorn a lac& of knowledp about

disability. Farnilies oficn attributcd a child's disability to the mother, blarning her behaviour dunng

pregnancy (such as excning henelf, or eating certain f d s ) or for making herself or the child

susceptible to contagious illness (even a respiratory infection). However, disability was also

fkquently explained as God's will. In this sense, disability was understood to be a test of patience

and faithfulness, or, less ofien, a curse. In general, the causes of acquired physical disabilities were

better understood, while ignorance sunounding mental disabilities and epilepsy led ro fear, and to

p a t e r isolation for those with mental disabilities, multiple disabilities, andlor seizures.

Respondents aitributed the stigrna of disability to differences in personal appearance, but

also to the Fdct that disabled people were without a full role in society, particularly an economic

role. A family member with a disability was seen as a wegiving burden (especially upon the

mother) and a financial burden. A CBR manager reported this rationale: 'You don't want to have

them because they're a burdcn. It's a poor society, that camot afford to care for people who are not

producing."

Respondents' descriptions of isolation, neglect and abuse of persons with disabilities,

usually inflicted by farnily membcrs, reflected how disabled people wcre sometimes considered less

than human, unable to do anything, and nat counted as family mcrnbers. They were often hidden

inside the home, which was especially tme for wornen and girls, for whom outside activities were

already culturally restricted. Farnilies believed that if neighbours knew of thcir disabled family

member, this would lessen marriage oppominities for sistcrs. "There is fmr of hereditaiy

disability," explained a CBR worker. Outside the home, negative attitudes fostercd discrimination

within education and employrnent scttings.

At the samc rime, the cornmitment to care for pcople with disabilities, which arose fiom a

arong mode1 of charity, \vas responsible for many charitable socicties and institutions, devcloped

and sustained by the wealthy and the generous. lnherent in this contradiction was the attitude that

the individual was a poor person, deserving of pity and help because of al1 he or she could not do.

Activists within the disability movement expressed discouragement with how, even within their own

constituencics, a lack of awareness led disabled people themselves to accept the charitable model.

CBR workers pointed out that of course iiot al1 people, or families, were the sarne. Within

a society of negative attitudes towards disability, individuals and families varied in characteristics

relevant to their outlook on disability. Receptiveness, understanding, willingness, cooperation,

adaptability, commitrncnt and motivation were mentioned, with religion and education also having

an influence. CBR workçrs made such observations:

It's different fiom family to another family. Sometimes they have a handicapped person, and they have the money and they have the ability to help him, but mentally they refuse to hclp him. Oppositely another family she doesntt have any kind of money but she needs to help her child .... It depends on the mentality of the people here, and their education or cultural situation.

4.2.5 Summarv

Within the Palestinian contexq, some fhctots hcilitated the developmcnt of CBR, such as

tight-knit communities and extended families. In general, however, the contcxt could not be

mnsidered conducive to the development of CBR when consideMg the authoritarian aspect of the

culture, die yrevailing medical mode1 of disabilig, and negative attitudes towards disabled people.

While these contextual factors were similar to othçr Arab countries, political circumstances

for Palestinians were different. These political conditions led to a unique expenence of CBR, in

which dissatisfaction with the above negative factors could be raiscd and rnobilized within an

atmosphere of social change.

4.3 Political Violence and CBR

4.3.1 The Conditions of Political Violence

Respondents described wo types of political violence: that imposed by the occupying

Jsraeli forces, and the teaction by Palestinians. The resulting conditions were generally referred to

as "Occupation" and "Intifada." niese conditions occurred simultaneously during the period

considered by tbis research.

It was also common for the words "Occupation" and "Intifada" to refer to periods of tirne,

with the former existing h m 1967 onwards, and the latter existing from 1987 until 1993.

Therefore, to avoid confusion, 1 refer to the conditions as "conditions of Israeii repression" and

"conditions of Paiestinian resistance."

The following conditions m r e commoniy identified by respondents as being relevant to the

developrnent of CBR. Thcy do not represent a comprehensive list of conditions of political violence

that were experienced at this time.

4.3.1.1 Conditions of Rcpression - The Occupation

Israeli authorities utilized a number of strategies to impose and maintain militas,

occupation.

a) Military administration of the Palestinian population.

Palestinians' livcs and affairs were govemed by Israeli rnilitary rule. With no self-

govcmance, there was a lack of social assistance programmes for the necdy, no control of

govemrnent education facilities, inadequate education funding, no control of govemment health and

rehabilitation services, and govemment health insurance that was both expensive and arbitrarily

adrninistercd. Lack of self-govemance contributed to Palestinian econornic underdevelopment, de-

development, and economic depcndence upon Israel. Palestinians cxperiçnccd high Icvels of

unemployment, and reliance upon "cheap labour" jobs in Israçl. Ultimately, poverty was the result.

This was combincd with inadequate government hcalth and rehabilitation senices, insufficiently

bolstered by health and social seMces that were provided &y NGOs in a fragmented manner.

b) Population dislocation.

Al1 regions in which the CBR programme operated had populations of Palestinian refugees.

These refugees were from areas that came to be within the state of Israel, and many still lived in

camps that were established aAcr the 1948 war. Basic services were provided to them by

UNRWA.

c) Administrative bamers.

The primary barrier was the requirement to attain written permits (called "permissions")

from the Israeli Military Authonty offices of Civil Administration. These included: permissions to

travel; permissions for CBR workers or children with disabilities to enter, attend or make

environmental adaptations within a schooi; licemes to open and operate a business. There were

many bureaucratic obstacles to aquiring permissions. Travel restrictions were enforced through a

cornplex system of colour coded identity car& (IDs), which were carried by every pcrson. Other

administrative bamers included taxation that was irnposed to inhibit development of business and

industxy.

d) Policies of civilian control and punishment.

These includcd closures and curfews, which were enforced by checkpoints and Street

soldicn. Restrictions were placed on movemcnt within and between the West Bank and Gaza, and

imluded long-term closures of the temtories. Control and collective punishment were also imposed

through school closures, blockades of roads and building entrances, house dcrnolitions, and land

cmfïscation. Gatherings of people were forbidden, and there was limited access to the mass media.

People were detained or arrested under a variety of military orders.

e) Violent military actions.

These differed from the above in that they were violent acts by Isracli soldiers, though

actually encouraged by officia1 policy. Actions against al1 members of Palcstinian society hcluded

shootings, tear gas use, forced entry, beatings, anests, threats, humiliation and harassment.

Soldiers used these actions against individuals and families, in homes, in public, in places of work

and education, and in clinics and hospitals. Violent actions resulted in injuries, disabilities, and

deaths. Medical problerns and disabilities were also found among released prisoners.

4.3.1.2 Conditions of Resistance - The intifada

The Paleainian people, acting as mernbers of organizations or as individual civilians,

responded with a vanety of strategies and actions.

a) Non-violent community resistance activities.

Resistance to Occupation coalesced into volunteer comniunity mobilization, beginning in

the late 1970s and the 1980s. Grassroots movements were fonned, for the purpose of organizing

social structures and services (for example, in economics, health, agriculture, women, culture, and

education). These movements accelerated dunng the hifada, with neighbourhood and national

cornmittees (NGOs) being cstablished. Non-traditional leaders ernerged, such as youth and women.

Non-violent resistance was also demonstratcd by acts of civil disobedience (for example, operating

a c h i c without a iiccnse), strikes, dcmonstrations, and the Israeli product boycott. However,

because motivation for nacional resistance was high, groups that espoused disparate political

affiliations crcated thcir otvn cornmittees and NGOs, along party lines. This factionalism within

community mobilization led to cornpetition for the peoples' loyalty and for ouüide resources.

b) Violent resistance actions.

The most cornmon form of violence \vas stone throwing, which was primarily camed out

by Palcstinian youth and children against Israeli soldiers. Stones were also throtm at settlcrs,

whose vehicles had yellow licensc plates (signi%ng Israeli or Jerusalem registration). There was

less fiequent use of gas bombs and fireams, resulting in injury, disability and dcath.

C) Escalating injury and disability of the Intifada.

Injuries were inflicted by Israeli soldiers pnmarily through shootings and beatings. These

usually, but not aiways, occurred during rcsponse to both non-violent and violent resistance

activities. Medical facilities and communities stniggied to cope with acute demands resulting fiorn

severe traumatic injuries and a sliarp risc in disability.

The "Intifada-injurcd" were in one sense a result of rcpression and resistance conditions,

yet Palestinians considered them to be far more than a group of casualties. They becarne a symbol

of resistance and a catalyst for further resistance due to their nurnbers and their status gained

through self-sacrifice. It a a s often said that every family had an Intifada-injured member.

ci) Intemational support.

The impact of international support was so significant that it became part of the social

fibric for the respondents. In this way, international aid and endorsement was more than simply a

consecpence of the political situation. UNRWA had been providing education, fôod and health

seMces for registered Palestinian refugees since 1948. Throughout the Occupation and

increasingly during the Intifada, the international community responded to the Palcstinian crisis

with relief and development assistance, often as expressions of political solidanty. Worldwide

publicity of Intifada-injuries stirnulated a sharp rise in support for rchabilitation initiatives,

including donations of money, equipment and technical expertise. International support spurred

institutional and cornrnunity rehabilitation programmes.

4.3.1.3 Summary

Aithough the repression conditions were severe, they were countered on a social and

motivational level by the resisîance atrnosphere. This interaction between repression and resistance

had widespread repercussions on social and community development in Palestine, affecting the

environment for CBR work and the actual development of CBR elements.

4.3.2 Effects of the Conditions of Conflict mon the CBR Work Environment

Working conditions of al1 Palestinians were very much afTected by the conditions of

political violence. The CBR workzn' daily duties revolved around such activities as home visiting,

public education sessions, cornmunit). and team meetings, and contacting refera1 agencies. Under

the circumstances of conflict mentioned above, there were significant persona1 and logistical issues

to be managed in getting CBR work done.

4.3.2.1 Conditions of Repression - Bamers and Threats

Since the CBR workers' duties involvexi accessing people with disabilities within the

community, the prime obstacles to their activities were the travel restrictions from checkpoints,

curfews, ciosures, permanent road blockades, and stri kes. Thesc were cornmon and m u e n t

hindrances in al1 regions.

CBR workers remained wlnerable to military actions even afier managing to rcach their

work setting. CBR team workers, like al1 mernbcrs of the community, were subjected to

harasment, threats, and use of tcar gas by soldiers. In addition, it was reported that soldiers on

occasion entered clinics and stopped CBR work.

Regular CBR activities were frequently precluded by disruptions ansing from the

Occupation and Intifada. When an arrest was made within a family that the CBR team visited, the

family was distrcsscd and pre-occupied. Whcn a villager w u killed, demonstrations and curfews

followed. Thcn,when the curfew !vas lifted, mcrnbcrs of the community, including the CBR

workers, set aside rcgular activities and sat in condolence with the farnily for several days,

according to custom.

4.3.2.2 Conditions of Resistance - CBR as Soiidarity

UPMRC7s programmes, and other NGO health initiatives, were pan of a cornmunity non-

violent resistmce strategy. Thus, despite the above dificulties, CBR workers remarked that a

sense of cohesion \vas fostered as they worked together, sharing successes and failorcs under

adverse circumstances. They described their own heightened self-rcliance, creativity and pride, in a

job ba t offered great challenge and interest due to the hardship. In addition, CBR workers

perceived that they demonstratcd thcir solidarity wvith the overall Palestinian political stmggle by

helping the Intifada-injurcd. As one worker explained, "we are part of them."

Violent community resistance rarely affected the CBR work. Occasionally CBR workers

who used cars with ycllow license plates (which indicated lsraeli or Jerusalem registration) risked

having their vehicln stoneû, if they were mistaken for Israeli settlers while driving through the

West Bank. This was rare, however, as the CBR workers became well hown within thcir districts.

4.3.2.3 Responses of CBR Workers - Belonging and Adapting

In response to the rnany travel restrictions imposed by thc Occupation, the CBR workers

adapted their methods of travel. Using their own initiative and knowiedge of their cornmunities,

CBR workers eventually ovcrcamç most restrictions with a combination of techniques, such as

avoiding checkpoints by using altemate routes, circumventing long lines by using yellow license

plated cars, or negotiating with soldiers to gain their way through.

In response to thc risk of stoning, the CBR workers adaptcd their rncthods of travel. Those

with ycllow-platcd cars rclied on siçns that idçntificd them as Arab drivcrs, which werc wcll

undc r s td within the cornmunity. These included placing a kirfi-ve (Palcstinian traditional scarf) on

the dashboard, and exhibiting "Medical Relief' signs in Arabic and English.

In responsc to military actions and vioience, the CBR workers expandcd thcir rolcs, botb as

comunity members and as UPMRC staff. They providcd social support to affected families, and

they assisted at the PHC clinics for the emergency medical needs that resultcd during disruptions.

4.3.2.4 Summary

The conditions of repression creatcd a very challenging environment for the CBR workers,

providirig obstacles and disruptions to their daily duties. However, these trials reinforced the view

that CBR was in solidarity with the Intifada, and participation in community rcsistance provided a

positive motivating aspect to the work. Overall, CBR workers adapted to their work environment

through flexibility, innovation, and role expansion. At the same t h e , howvever, the conditions of

confiict had significant impact upon vanous elements of the CBR programme itself.

4.3.3 Effects of Political Violence on CBR Eiernents

4.3.3.1 Promoting Positive Community Attitudes towards Disability and People with

Disabilities

Respondents stressed CBR's emphasis on creating positive and lasting changes within

cornrnunity beliefs, kelelings, and behaviours towards people with disabilitics. LJPMRC

incorporated this goal into al1 aspects of its CBR activities, fiom CBR worker interactions in the

home and neighbourhood, to policy directions taken by the organization. This reflected the

community development aspect oFCBk in that attitudinal change was at least as important as the

provision of rehabilitation services.

4.3.3.1.1 Conditions of repression - Sustaining negativity

Occupation was noted to negatively affect the promotion of positive attitudes towards

disability, in two ways. First, respondents noted that the severe economic repercussions of

Occupation caused both families and society to relegate disability concems to a low priority.

Negative attitudes towards people wvith disabilities were arnplified because of the financial burden

of their care on families who already experienced economic hardship.

Secund, policies oCOccupation hindered CBR efforts to improve attitudes. Restrictions on

public gatherings and lack of access to the mass media obamcted public education activities of

people with disabilities and the CBR tearn. Also, special permissions were required fiom the

authorities for the CBR team to enter the schools for public disability awareness and education. It

was a difficult process to obtain permissions, and they were rarely granted.

4.3.3.1.2 Conditions of resistance - Catal yst for change

In contrast to the above, conditions of resistance positively influenced CBR's promotion of

positive attitudes. The symbolism of the Intihda-injured and non-violent community resiçtance

each played significant roles.

Respondents widely reported that public consciousness of the Intifada-injured improved

attitudes towards disability. The Intifada-injured were called a "wake up" to socicty, and a

stimulus towards disability awareness. Whereas they were previously hidden, peuple with

disabilitics became suddçnly far more visible as a result of the large number of Intifada-injured.

They wcre also proud to be seen in the streets, for society considered them "heroes" who had

acquired their disability through personal sacrifice to the political cause. A CBR advisor

expiainai, "Because of the passion, and the confrontation, and the heroisrn of w h t Our young

pcople passed through, and they became disabled aAer their injury, aficr ihcir beating, after their

shooting - sa, they became aware that the disability is some kind of honour for thcrn."

Signifimtly, respondcnts with disabilities declarcd that the statu of the Intifada-injured

markedly improved attitudes ivithin the disability community itself. ïhis was echoed by a CBR

advisor, who said, "The most important change has becn in the gradua1 shifi in the attitudes of the

disabled themselves."

In direct response to conccm for the Intifada-injured, local and foreign contributions were

made to improve institutional rchabilitation services, which ultimatel y bencfitted al1 people with

disabilities. A CBR worker noted that this lcd to a broader perspective towards disability amongst

health and rehabilitation workers. This "new, open-rninded" approach to disability, which was

introduced by foreign rehabilitation initiatives, was noted by a CBR manager to have provided an

impetus to attitude change within society.

Esteem for the Intifada-injured, however, did not simply convert negative attitudes towards

disability into positive oncs. A CBR worker rematked of people's feelings towards the heroes,

"They give them this status, but ioside they are feeling vezy pity, very sad." Though sorne

respondents claimed that al1 people with disabilities benefined to the point of being considered

qua1 to the "heroes," most respondents noted that the status of the injured induced a fom of

discrimination between categories of disability. Thus, it was suggestcd that people with disabilities

gained unequally fiom the positive changes in society. One CBR manager assessed the inequality

by saying, "It dwsn't give any kind of advantage to those who are not Intifada cases, in terms of

their position in the community, of the perception of people towards hem, which reflects their own

self-esteern and their own self-redization." Similarly, a CBR advisor expressed reservation; "1

dont know how much attitude has changed gencrally, within Palestinian society." Overall,

respondents prcsented a balanced optimism regarding the long-tcrm cffcct of the Intifada-injured

upon society's attitudes.

At the same time, non-violent resistance of the Intifada charactcrized by widesprcad

community mobilization, positively affectcd the CBR team's ability to affcct change in attitudes.

Respondents said that the spirit of resistance and grassroots activisrn made society more responsive

and less rigid. Responsiveness and ddmamisrn facilitated comunity work, in this case the CBR

initiatives towards raising populûr awûreness of disability issues. Thus, a CBR manager said this

aspect of the work was made easier d u h g the political cnsis: "lt's easier. It's not more difficult.

Easier because people are more mobilized, more able to perceive, more positive in terms of reaction

to initiative, and more socially linked, interactive.. . . Bccause you are talking about resistance herc."

4.3.3.1.3 CSR programme responses - Building upon awareness

In response to the hindnnces nhich Occupation policies placed upon initiatives to improve

attitudes, the CBR team adûpted its methods of accessing community members. People were

contacted individually or in srnall groups, outside controlled locations and governmental

organitations such as schools.

In response to the genenlly positive attitudes towards the Intifada-injured, UPMRC

adapted its CBR mandate by expanding its focus to include the Intifada-injured within their rural

rehabilitation work. They joined with other Palesthian organizations in publicizing the political

cnsis affecting health and disability, including the situation of the Intifada-injured. Capitalizhg

upon improved awareness and attitudes, bey acquired and distributed benefits equally to children

and adults with disabilities, without prefercnce to the Intifada-injured. At the same time, CBR

workers adaptcd their methods of working with the Intifada-injured, in light of thcir new status.

CBR workers encouraged individuals by reminding them, "You are respectcd by al1 the community,

and you have rights."

4.3.3.1.4 Sununary

While repressive conditions of Occupation helped to sustain prevalcnt negative attitudes

towards disability, the lntifada had a great impact towards tmnsforming hem. Cornmunity

mobilization, which encouraged public disability awarcness initiatives, was no doubt important, but

the esteern in which the Intifada-injured were held was key in improving attitudes. It was clear,

however, that a tmly far-reaching impact was undermincd by general society's emerging distinction

between the herocs and other people with disabilities. Nonetheless, positive changes in attitude

were substantial within the disability cornrnunity and among those working with people with

disabilities, which was an auspicious beginning for the development of positive community

attitudes to disability.

4.3.3.2 Promoting Integration of People with Disabilities within Society

The second element of CBR is strongly linked to the first. Positive attitudes are a first step

towards the integration of people with disabilities, and integration may be an indication of positive

attitudes. Integration is the process of becorning active within society, particularly in assuming

accepted roles within the fmily, school, and workplace. The UPMRC CBR programme

emphasized that society should become inclusive of people with disabilities, not simply expect

people with disabilities to lcam skills for adapting to the status quo. At the same tirne, integration

was also influenced by the availability of adaptive equipment and medical rehabilitation services,

which will be considered in the final hvo CBR elements.

4.3.3.2.1 Conditions of rcpression - Blocking employment and education

Repressive conditions invariably had a negative effcct upon the integration of people with

disabilities within society. Specifically, travel restrictions, economic undcrdcvelopment and

unemployment, administrative barriers and military administration werc idcntifiçd by rçspondcnts

as inhibiting factors to integration.

Travel restrictions scriously hindcred the abilil of people with disabilities to be active

outside the home, to gain access to jobs, and to meet togcther. Vocational training and employment

were often available only outside their o\vn villages, and CBR workers fiequently notcd that those

with disabilities had fcwcr and lcss flesi bfe options for transportation. Furthemore, people with

disabilities descnbed their dificulties in meeting togcthcr to create disability organizations, citing

problems in gaining petmissions to travel, in extra travel required to avoid closed areas, and

harat ion in having to continuously alter $iris in the face of curfcws and disruptions.

Although high unemployment affected the entire population, people with disabilities were

noted again to be particularly hard hit. Obstacles sternming fiom negative attitudes and

inaccessibility meant that options for gainfil emplo.ment were fewer. In addition, most jobs open

to Palestinians in Israel were noted to be in rnanual labour and construction, which were unlikely to

be offered to people with disabilities.

For disabled children, administrative barries pose. a significant bar-ier to integration by

limiting access to govemment schools. Regulations required headrnasters to show that speciaI

permissions fiom the Civil Administration had been aquired by the parents. As noted earlier,

while permissions could be obtained, the process was long, difficult, and fiequently unsuccessfiil.

Within the Civil Administration, bureaucrats created obstacles to obtaining al1 permissions.

A CBR worker described how the appropriate authority would absent himself repcatedly when he

was approached to receive applications. Another CBR worker described how a rnilitary official

had denied permission for a child's entry into a regular classroorn. In that case, the official had

simply stated that regular school tvas unsuitable for a disabled child and that she must find a

special school in the Central rcgion.

Likcwise, for structural adaptations to irnprove physical accessibility, and for the CBR

workers to assist teachers with integration of children, the same bamer was encountercd. A CBR

worker explained, "it was difficult, in some places it was evcn impossible, to entcr schools, because

we need to have a special permission." Finally, schools suffered from a lack of education fùnding,

equipment and support, so that teachcn were largely unable to absorb students with extra needs. A

CBR worker concludcd that for those reasons, the disabled child "tvill cnd up swing at home."

Integration \vas also affected by military administration, undcr which there were no laws

regarding nghts for people with disabilitics. CBR workers expressed the need for mandated

disability rights and services, for example the right to accessible schools. Military rule precluded

irnplementation of disability legislation that had been draAed by Palestinian lcgal and human rights

advocates. Respondents cited this powerlessness as contributing to the maintenance of

discrimination in tmsportation, ernployment, education, and accessibility. At the same time,

Palestinians were becoming aware of the legal protection and broad social assistance available to

people with disabilities in Israel. Respondents noted that cornparisons with Israel elicited various

reactions, ranging fiorn discouragement and bittemess, to a cornmitment to create similar

advantages for Palestinians .

4.3.3.2.2 Conditions of resistance - Deserving a place

In c o n t r a to the above, the status of the Intifada-injured positivcly affected integration.

The number and the pnde of injured persons made disability more visible, and respondcnts

observeâ that society came to accept that people with disabilities would assume the social roles that

were available to non-disabled people. One CBR worker noted how segregation was confrontai,

saying, "You don't isolate the hero. On the contrary, he has to be a good example for the society."

Respondents noted that being injured in the Intifada allowed people with disabilitics to become

contributing members of their fmilies, highly visible on the streets, and active within schools and

universities. This in tum encouraged the same participation from other pcople with disabilities.

The Intifada-injured were usually young men, previously able-bodied and active, who were

a syrnbol of strcngth and, owing to their self-sacrifice in resistance, were considered entitled to

demand accommodation by Palestinian society. They sparked the development of the General

Union of Palestinian Disabled, whose membcrs said that the improved awarcness and attitudes

encouraged by the Intifada-injured "aimulated us to move." With this catalyst, the GUPD set out

an agenda that focused upon disability iegislation and integration issues. For example, despite the

lack of legal requirements for making public places accessible, new construction began to

incorporate these features after the GUPD, which formally represented disabled people, approached

the leaden of municipalities and educational institutions.

4.3.3.2.3 CBR programme responses - Advocacy and support

Many of the obstacles to integration irnposcd by the Occupation, such as economic

restrictions, were considerd beyond the CBR programme's ability to address. However, in

response to administrative bamers, CBR worken stressai their advocacy role. With families, they

penisted in applying to thc Civil Administration for school permissions. In addition, CBR workers

approached school personnel, outside the school buildings and on a personal basis, to support the

cases of individual childrcn.

LJPMRC also rcspondd to lack of legislative ability, at the same time capitalizing upon Ùie

momentum created by the Intifada-injured within the disability movemcnt. UPMRC incorporated

within its mandate a strengthcning of the GUPD, and this was camed out at both UPMRC's

administrative and local levels. For exarnple, UPMRC used its position among hecilth and

rehabilitation NGOs to endorse the full status of the GUPD on the CNCR. Regionally, the CBR

workers facilitatcd development of local branches of the GUPD. Thus, UPMRC acted both in

response to the disability movement, and in direct support of its formation. Mcmbers of the GUPD

identified extensive UPMRC logistical and moral suppon, both in public and in private, sayuig that

CBR was its "first fiend."

4.3.3.2.4 Sumrnary

The repressivc mcasures of Occupation had a marked detrimental impact upon integration,

especially within the ernployment sector. In the face of serious restrictions and economic

challenges, the CBR programme lacked successful measures to achieve integration in the

workplace. However, the conditions of rcsistance, chanctenzed by impetus from the

intifada-injured, assisted the CBR programme and the new disability movement to make gains in

the integration of people with disabilities, notably into family and social life.

4.3.3.3 Transferring Rehabilitation Knowledge and Skills

This element was undcrstood as the training function of C B S which involved teaching

people with disabilities and their family members how to utilize rehabilitation principles and

exercises to achicve hproved phy sical and social hinctioning. Transfer of knowlcdge and skills

was particularly emphasized by the CBR workers, who were intensively involved as trainers on a

&ily basis, mostly during home visiting.

4.3.3.3.1 Conditions of repression - Unable to deter

Interestingly, repressive conditions were not notcd to impcdc the transfer of rehabilitation

knowledge and skills, once the CBR workers were able to reach the home. One CBR worker made

this clear: "When it cornes to this, there is no direct effect of the Occupation. Thcy cannot corne

inside the housç with a frunily and prevent us, the rehabilitation worker, from teaching the skilts to

the family. They cannot do this."

4.3.3.3.2 Conditions of resistance - Motivation for independence

Upnsing conditions had a positive influence upon rehabilitation training, though indirectly?

in the sense that those disabled du ring resistance activitics had a high motivation for regaining

independence. Since both the Intifada-injured and their socich, interprcted their injuries as hcroic,

they gained a scnse of power and a will to rctum to society. A CBR workcr detailed how many

Intifada-injured young men, aAer an initial pcriod of shock and depression, wantcd to reassert their

strenyi: 'They want to prove that they are still strong, and they can still be a member of the

society with the same power .... The role now is how to go back to society with the maximal

capacity. And you will see them learning so fast Very quickly, and they are willing to leam."

It was also suggested, though by few respondents, that the cornmunity mobilization of non-

violent resistance may have assisted self-help initiatives in which there was a transfer of knowledge

and skills. The general spirit of self-reliance was thought to have enhanced people's receptiveness

to training that could lead to greater independence.

4.3.3.3.3 CBR programme responses - A political spirit

Responding to the ideal of Palcstinian self-reliance, CBR workers linked the transfer of

skills with self-sufficiency. They encouraged people with disabilities and their families to use the

education and training resources that the CBR programme offcred, implying that a spirit of

independence was irnperative within the political circumstances. A CBR worker said that she

asserted this during home Msits, when she would Say: Who else will do this for you? Because no

care is provideci to us, you must do what you can on your own.

4.3.3.3.4 Surnmary

Other than hindranccs to tnvel, which the CBR workers generally overcame, thc training

element was not significantly affected by the conditions of repression or resistance. Cases of

Intifada-injury werc not predominant within the CBR programme, so thcir overall influence upon

this element likely was limited. Other reported positive cffects of resistance were not widely

endorsed.

4.3.3.4 Providing Participant-Directed Rehabili~tion Services

UPMRC CBR services were available in each regional project, and included physiotherapy

assesment, disability education and training, assistance rvith acquiring equipment, refenal, and

support in dealing with public and rnilitary authorities. This CBR element reflected the ability of

programme participants to express their disability needs and thereby direct rehabilitation services.

During in te~ews, this concept rvas contrastecl with situations in which predetenined seMces

were imposed, based only upon the prionties of service providers.

4.3.3.4.1 Conditions o f repression - Learned helplessness

Respondents suggested that political powerlessness expcrienced while living under military

administration had resulted in Palestinians being unprepared in general to define their own needs,

and to initiate, plan, and control their lives. This was also true for disability ne&, an4 despite the

awarcness of some people with disabilities about the disparity of services betwecn Israelis and

themselves, many Palestinians ~vcrc ignorant of what services could be made available. A

respondent with a disability cornmented that the military authontics ignored rehabilitation issues in

order to prevent social development: 'They like the situation as it is: people are not aware of what

they need."

4.3.3.4.2 Condirions of rcsistance - A stronger voice

The Intifada stimulated a powerful awarencss of disability and rehabilitation neais, which

gave an opportunity for these to be esprcssed. At the individual level, the Intifada-injured were

considerd entitled to make demands of rehabilitation services. A CBR manager illustrated this,

emphasizing integration issues:

Now, the Intifada has brought a stronger pcrson. The stronger person is a penon who hm faced soldiers. He is arong in that, so why not to look at him also as strong person while he is disabled? ... So they started to speak out, even to speak out about their necds - 1 want a wheelchair. 1 want to go back to my university. 1 want to go back to the school.

At the organizational level, new international support brought sophisticated rehabilitation

faciiities and equipment. While these institutional services were ultimately available to al1 people

with disabilities, priorities were initially set in Palestinian society for the care of the

Intifada-injured. Thus, spccial arrangements which were made for those injured by violence

reinforced thcir status, and meant that they were more likely than other disabled persons to have

their rehabilibtion needs met. A CBR worker stated the situation simply, "Because of the Intifada,

if they need somcthing for disabled person they know that they'd get it. They keep asking for it."

4.3.3.4.3 CBR programme responses - Pragrnatism and vision

In reaction to the disability needs of the Intitada-injured becoming a priority over others,

the CBR programme adapteci its mandate to balance the interests of both groups. Howevcr, a CBR

manager noteû that the programme wvas "aware of the fact that people with Intifada-injury need

certain amount of cxtra a re , because of national reasons mainly. Political rcasons." Thcrefore,

although UPMRC explicitly identified the Intifada-injured as beneficiaries, it continucd to channel

resources primarily towards rural areas and cliildhood disability. In addition, UPMRC sought to

know, addrcss, and balance both the long-term strategic needs and the shon-term imrnediate needs

of those receiving services.

4.3.3.4.4 Summary

In addressing participants' direction of services, respondcnts focusscd upon how

Occupation and Uprising afEected people's knowledge and expression of their needs. The ability of

Occupation to prevent disabled people from being aware of possible services \vas a factor in

isolated villages and places where NGOs and charities were not working. At the same time, the

Intifada-injured were a potent factor throughout the country for increasing awareness of disability

needs and demanding service provision. UPMRC's approach addressed the concern that this

awareness and articulation of need disproportionately benefitted the Intifada-injured, in contrast to

others with disabilities.

4.3.3 -5 Implementing the Programme with Community Participation

This element addressed the 'community-based' aspect of CBR. Community was usually

interpreted geographically, as the residents of the village or town where the CBR t m was

working. Respondents rarely addressed specific concepts of community accountability or

decision-making within the programme, preferring a broader discussion of community involvement

or cooperation. Participation ranged from endorsement and moral support, to volunteering and

contributing to CBR activities.

4.3.3.5.1 Conditions of repression - Depleted capacities

The severe economic repercussions and stressfil violent events that communities faced

under occupation were cited by respondents as affecting participation in CBR. It was natural, they

said, that many community rnembers addrcssed their otw pressing econornic and social concems

ahead of the disability necds of others, and fcw were able to commit themselves to volunteer

activities.

Rcspondcnts also indicated that the refugee expenence had a marked c f k t upon the

Paiestinian community, resulting in prolonged dependence upon UN relief mcasures, which

hindered community participation and self-reliance.

Ironically, thouph, it \vas suggested that lack of self-government also implied an absence of

bureaucratic obstacles that can characterize operations through sovemment oficials. A CBR

advisor commented that this allowed CBR programmes to benefit from the work of communiiy

activists: "But here, active peopie with initiative, motivated people can al1 have a Say. People can

affect change. A broader spectrum of people."

4.3.3.5.2 Conditions of resistance - Activisrn in the stiadow of partisanship

Increasing resistance to Occupation positively influenced community involvement in CBR.

Non-violent community resistance, characterized by the grassroots movements of issue-based

popular cornmittees and NGO formation and cooperation, also ârew community mernbers into

disability work. People joined organizations in a spirit of resistance and cornmitment, which a

CBR advisor explained by saying, "People were aware that without unity at lcast - with the daily

life ne&, with the problems of everyday, disability, poverty - without uni- they can do nothing."

In this environment, the Intifada-injured were a common focus of concern and caring, and a catalyst

to community action in disability.

Howcver, it was noted that conununity mobilization marred by political factionalism,

when some cornmittees and NGOs sought political gain fiom their rehabilitation service activities.

A CBR advisor noted the impact of factionalism upon CBR when using the WHO village

cornmittee model:

You know you form a cornmittee in this countn, immediately the formation is political. You choose this part and that part, and you get the wrong people - mcn who are in political power. And they think they want to take over this project and use it for their own purposes. And the next thing o u know, it ignites fights among the people.

Factionalism occasionally led to cornpetition among rehabilitation organizations, however

respondents noted that its impact was less, and cooperation greater, witliin CBR than with other

health and social initiatives. This was perhaps due to consensus surrounding the cause of

disability, as syrnbolized by the Intifada-injured.

4.3.3.5.3 CBR programme responses - Building new models

In response to the economic pressures upon community members, UPMRC exarnined and

rnodified the CBR model of voluntcerism. CBR workers were paid. In addition to enlisting

conventional volunteer support, a CBR advisor explained how they worked to "reconstmct the

notion of volunteer in tems of 'selective assistant at times'." This involved cornmunity members

assisting with the CBR programme by donating tirne and talent within their oivn employment. This

assistance could mean, for ewmple, transportation from taxi dnvers, apprenticeship with

craftspeople, or g d s from merchants

UPMRC reacted to, but was also a major player within, the general community

rnobilization during the Upnsing. UPMRC invited participation in the CBR programme by

approaching communities as partners in resistance, to address disability needs through CBR.

According to a CBR manager, it was casy for UPMRC to start a dialogue with communities bascd

upon thc sharcd assumption that, under the constraints of Occupation, people's necds could only be

met by coopcrative action.

Organizations working in rehabilitation chose CBR as a kcy mcthod of addressing

disability issues and providing services. A CBR worker explained how political resistance and

community responsibility were linkcd in rchabilitation initiatives: 'We t a n t to control our life.

We want to be indcpcndcnt from thcm. We wiII not wait for tbat [Israelij Civil Administration

corne with project for disabled. No, we will do it for ourselves."

In response to the risks of political factionalism, WMRC adaptcd its usc of local disability

cornmittees. lnstead of initiating projccts with local cornmittees, regional teams gained infomal

cooperation of local people who were aircady active in disability issues and who were accepted

within their communities. CBR work procccdcd with this nucleus of committcd pcoplc (usually

women, often moihcrs of children with disabilities) who participated in project decision-making

with the team. Links were thcn made with community leaders for validation of the process. in

addition, UPMRC addressed factionalism by forrnally cooperating with the CNCR and the GUPD.

UPMRC partnered with a second health NGO, integrating staff and responsibilities in the creation

of a CBR project in the North rqion. The CBR team also dealt wvith factionalism at the project

level, by convening village meetings in which a balanceci representation of all concemed groups

focused on addressing disability n e d s in a cooperative m e r .

4.3.3.5.4 Summary

Conflict conditions had signifiant effect upon c m u n i t y participation in CBR.

Repression conditions challengeâ and oAen overame people's capacities for volunteering, since

they were pre-occupied with simply meeting personal and family needs. In response, the Intifada

set the stage for CBR, building on the essential component of community mobilization in the

resistance. Strong political motivation for high-profile social action initiatives triggered community

response to disability issues, which then developed into CBR initiatives. This also rcsulted in

innovation in CBR conmittee models and partnership approaches. And tvhile community

involvement in CBR was threatened by vulnerability to political divisivcncss, factionalism did not

overcome cooperative work in disability.

4.3.3.6 Exhibiting a Modcl of Partnership among Pcople with Disabilities, Familics, the Cornrnunity, and Rehabilitation Personnel

Partnership within CBR was explained in ternis of meaningful contribution and equal

status among CBR participants, within their differing roles. Respondcnts were asked to what

degree the programme treated all participants equally and with respect. In order to clan& the

question, this concept was contrasted with a scenario in which a hierarchy existed, with the doctor

most senior, followed by the physiotherapist, the rehabilitation wvorker, the family, and finally the

person with a disability.

Respondents from al1 categories clcarly identifid with this concept and indicated that their

perspectives and opinions were valued by others. However, many respondcnts explained that

cultural faftors within Palestinian society (previously noted) were also at play, obstructing a tmly

non-hierarchical programme. It was apparent that this issue was a sensitive one, perhaps because

the ideal of an equitable society lay at the k a r t of Palestinians' struggle for democracy.

4.3.3.6.1 Conditions of repression - Reinforcing divisions

Respondcnts noted b a t curfews, travel restrictions, and security concems caused CBR

teamwork to become fragmented. There were many occasions when the full team was unable to

work together, threatening cohesion and partnership. This occurred when team mcmbers with

cerrain IDs or car license plates were not permiîted entry to villages. Disruption aiso resulted fiom

the threat to male workers, including doctors, who were at greater risk of arrcst by soldiers than

wornen health and rehabilitation workers.

4.3.3.6.2 Conditions of rcsistance - Ideals of equity

Partncrship was facilitated by thc elcvatcd stanis of the Intifada-injurcd and the rcsulting

improved attitudes towards people with disabilities. Thcy, and their fmilics, bccame confident in

taking new roles within thc CBR prccess. A CBR worker notcd, "They want us to go to their

houses, to work with thcrn like a team. They arc sharing, and we are sharing wvith thcrn."

At the same time, conccp!s of democracy, social equity and participation that underlay the

grassroots movcments were rcinforced during the Intifada. Popular committees and NGOs sought

to convey these concepts into action, by recruiting people fiom al1 leveis of society to coopcrativcly

address broad social needs. In this wvay, UPMRC gained a committed group of CBR worken.

Significantly, while women, young people and people with disabilities began to express their views

and shape society in challenge to lsraeli milita^ authorities, they at the same time challengecl their

own authorhian culture.

A few respondents, from al1 categones, assertcd that there was no discrepancy in status

within UPMRC's CBR programme, with al1 participants being equal and respected. Another view

was expressed, perhaps a more realistic one, that a tme mode1 of partnership \vas still an ideal,

though UPMRC was attempting to realize it. A CBR manager, himself a male doctor, s u m e d this

up by saying, "Our goal is not a hierarchy, but actual life is something different. There are good

steps with this in Medical Relief, but the culture is authontarian and hierarchical."

4.3.3.6.3 CBR programme responses - Interdependence among workers

The fragmentation of CBR tearnwork caused by curfews and travel restrictions

necessitated a sharing of duties. Each person Iearned others' roles, and, by covenng for one

anothcr, understood and appreciated each other's work. This response produced a positive result in

tems of partnership.

Similarly, CBR workcrs' responsc to sccunty problems had a positive effect for pamicrship

within the team. While male doctors wcrc concalcd, female CBR and village health workcrs were

respectcd for working more visibly, and for challenging soldien who tried to arrest the men. Thus,

within the UPMRC PHC and CBR teams, there emerged an equalizing force between female

workers and the tradi tionally powerfil male doctors.

4.3.3.6.4 Summary

Conditions of Occupation were not highly relevant to the issue of incquity in working

relationships, although responses to repressive measures created a positive environment for

partncrship. Palestinian culture itself was considered to be the prima. impcdiment againa a mode1

of partnership within CBR, indeed within society. Against this bamer, the dernocraiic ideals

underiying the grassroots movements of the Intifada exerted a positive influence upon CBR

programme participants, and made some impact.

4.3.3.7 Using Locally Made Rehabiiitatic:: Aids and Equipment

The UPMRC CBR programme made extensive use of both simple, village-made items, and

more sophisticated items that m e fiom larger Palestinian workshops. Simple rehabilitation aids

were usually fibncated fiom wood by a village carpenter, and included standing and seating

equipment for children. Items such as prostheses, orthoses and wheelchain were made in

institutional workshops. Educational equipment and therapeutic toys were obtained fiom sources

within villages and the central region. The evolution of this system was largely due to political

factors, as will be shown.

At the s m c time, the programme accessed a wide variety of imported rehabilitation

equipment, such as exercise equipment and wheelchairs, particularly for thc physiotherapists'

work. High technology rehabilitation equipment, such as cornputer-assisted dcvices, was not

accessed by the CBR tcarn from any source.

4.3.3.7.1 Conditions of rcpression - Small-scale technology options

Overall, the econornic and travel conditions of the Occupation lefi the population with little

choice but to use simple, village-made options. Poverty contributed to families' inability to afford

rehabilitation aids. A CBR worker comrnented, "the rnoney which are not enough, they go to more

basic life needs - like food, like rent." So, although some charities offered assistance, most people

with disabilitics went without assistive devices. At the sarne time, lack of cconomic development

and investment discouraged the establishment of equiprnent workshops, thus ensunng reliance upon

Israeli and imported rehabilitation products for the few who could afford them. The presence of

sophisticated and espensive items sometimes elicited dissatisfitction with simple local products that

were offered within the CBR programme. A CBR advisor explained, 'While we are talking about

tree branches in Gaza, people know that there is an electronic wheelchair half an hour away .... And

they dont want to have one and cannot afford the other, and therefore will end up with nothing."

Manufacture of ans equipment beyond very simple aids was dcpendcnt upon skilled

craftspeople and adequate materials. Vanous economic factors had caused a scarcity of skilled

craftspeople, which was said to have "depleted the foundation for technology." These factors

included the tendency for a large number of workers to be &y-labourers in Israel, and family

pressure for professional education for young men, so that they might have the ability to eam more

money and perhaps emigrate. And while curfews, closures and stnkes limitcd the availability of

rnaterials, they also preventcd CBR workers from gaining additional training in making

rehabilitation equipment. This was illustrated by a CBR advisor: 'We established a workshop for

muiufacturing the wheclchairs. Three of the workers hcre were selectcd. Thcy had to take thcir

course in Jenisalem. The course passed, and we didn't get pcmits for them to go."

nius, travel restrictions highlighted the impracticality of reliance upon outside resources.

Simple alternatives w r e developed because it was difficult to acquire or maintain sophisticatcd

rchabilitation equipmcnt.

4.3.3.7.2 Conditions of resistance - Sophisticated relief versus self-sufliciency

Uprising conditions both discouragcd and fostered Palestinian self-sufficiency in

rchabilitation tcchnolo~. Prirnarily, the intcmational rcsponse to the well-publicized needs of the

Intifada-injured had a large impact.

international donations of rnoney and rchabilitation equipment, though greatl y appreciated,

discouraged development of local rehabilitation technology. For example, the high profile of the

Intifada-injured initially singled them out to receive sophisticated equipment, either directly or

through special fùnding for equipment purchases. As a result, the Intifada-injured generally

aquired supenor equipment, in cornparison with other disabled persons. So, while injuly in the

Intifada increased disability awarencss and prompted Palestinians to meet their rehabilitation

equipment ne&, the influx of assistance discouraged the development of sustainablc village-made

options.

Similarly, international groups and organizations also provided equipment to Palestinian

rehabilitation programmes which served the needs of al1 disabled persons. Such programmes

included UPMRC CBR. A CBR worker remarked, "If we have no choice, we go back to them

[simple ai&] and we are really making good use of that. But, in other way, we are not using al1 the

[local] resources, because we have access to better."

Nonetheless, and fortunately in a sense, foreign-made rehabilitation equipment was

frcquently found to be inappropriate within the Paleainian context, particularly to withstand the

harsh environment of village homes and streets. ïhis incompatibility encouragcd initiatives to

develop more suitable local products. Substantial international devclopment support then hciped to

establish manufacturing workshops within Paiest inian rehabili tation institutions . Europcan

govemments and NGOs were larsc contributors to institutions located in the central arca - in

Jcrusalem, Rarnallah and Bethlehem. It was thcn possible to produce necdcd products, such as

orthotics and prosthctics, at a cost lower than imports. It also crcated a source of trained workers

in rehabilitation technology. A CBR worker spoke of these institutional initiatives: "During the

Intifada we got more support from abroad to build this selfdependence, independence, on our own

human resourccs or our own technology - instcad of importing it frorn Isracl and frorn abroad.

Organizations, for political rasons sornctimes, they hclpcd us to be independent from Israel."

4.3.3.7.3 CBR programme responses - Keeping options open

The CBR programme responded in two ways to international actions in the arca of

rehabilitation technology. On one hand, the programme took advantage of donatcd equipment, and

solicited funds to purchase imponed goods. On thc other hand, it supported the technology

initiatives of Palestinian institutions and their international partners, and accessed those local

resources.

In response to a lack of skilled local worken, CBR workers sought local carpenters to

mate rehabilitation ai& and equipment. The CBR worken guided the manufacture, which was

described as being "by copying, but not by imagination."

in response to travel restrictions that impeded movement of goods, UPMRC used their

network of linked PHC and CBR tcams to supply needed rehabilitation aids and equipment fiom

central locations. It was noted that this was not difficult since UPMRC had gained expertise in the

distribution of essential drugs throughout the Intifada.

4.3.3.7.4 Sumrnary

The conditions of Occupation and Upnsing provided the CBR programme with a compler

scenario of inccntivcs and disinccntivcs to using local rehabilitation tçchnoiogy. What emcrgcd in

this situation was a flesiblc and broad definition of 'local.' Equipment was considcrcd local if

Palestinian labour and materials were usd. Accordingly, local equipment included simple, village-

made itcms, as well as the more sophisticated items fiom Palcstinian institutional workshops in the

central region. The latter became availablc only through international developrnent assistance.

Thc CBR programme used both local and irnported quipment, according to what was

appropriate, neccssary, or easy under the overall conditions. Local products were chosen over

importcd oncs when they werc available and at lower cost, and because political sentiment

encouraged this practice.

4.3.3.8 Participating in a Refcrral Network with Specialists and Institutions, for Professional and Technical Rehabilitation Support

A referral nehvork was defined as the link between the CBR programme and medical

specialists, tcrtiary care Fdcilities, rehabilitation hospitals and physiotberapy clinics. Such a

network was not conceivable pnor to the IntiFadq due to the lack of rnany of thesc services for

Palesthians.

With substantial international assistance, the Uprising spurred the dcvelopment of tertiary

services, and a referral network began to be established. UPMRC CBR participatcd in this

network. Relations between the comrnunity programme and rehabilitation specialists were

characterized by mutual respect and open communication. At tbe time of study, CBR participants

were identifjing the necd for rcgional intemcdiate lcvel seMces to be developcd, providing

occupational, speech and physical thcnpy.

4.3.3.8.1 Conditions of rcprcssion -- lmpeding dcvelopment and acccss

Occupation conditions were invariably reported to negatively affcct thc development of a

rcferral network. Bcfore the Intifada, the cornponents needcd for a refcrral system wcre largcly

unavailable, such as rehabilitation institutions and adequate professionals. Latcr, whcn specialized

services were developed, repressive conditions continued to obstruct access by comrnunity

p r o g m e s .

The only rehabilitation services provided by the military authorities were small

physiotherapy depaitments in a few of the governent hospitals. Limited care \as available for

people with disabilities, provided primarily within smali institutions run by charitable societies. A

CBR advisor highlighted thc repressive cffcct of military administration on this elernent of CBR,

saying that a comprehensive approach to rehabilitation "lies within thc establishment of structures

through which CBR could link, so that services could be provided, and needs could be met .... It is

very difficult for this to happen under Occupation, because there must be a state structure that has

a clear policy."

In very serious cases, referral to medical and rehabilitation facilities in Israel was made.

The mst of such treatment, however, was extremely hi&. Few Palestinians were covered by the

necessary Israeli health insurance and if they were, there was no guarantee of receiving the benefits,

as the process was subject to the arbitrary management of the Isracli authority7s office of Civil

Administration. When referrals were made, CBR workers described communication between

themselves and Israeli hospitals as being virnially impossible.

Later, when Palestinian rehabilitation institutions were created and expanded, rcpressive

conditions of curfkws, closures, strikes, and lack of travd permissions made the institutions

inaccessible to the vast majority of Palestinians. A CBR advisor spoke of their cooperation with

the new facilities: "There are no problems with the service. But the problcm is with how to reach

[them]." Even when those in need could reach the institutions, thcrapists and doctors were hindered

in reaching their place of work, and specialists were similarly restricted in rnaking regional

outreach visits. A CBR worker described such incidents: '%en I cal1 them to refer some of the

w e s to hem, they will tell me, 'I'm sorry. 1 cannot accept your case because that person is not

available. He is stuck in his a r a - curfew'."

4.3.3.8.2 Conditions of resistance - Capacity-building and cooperation

In contrast to the above, conditions of resistance spurred the development of a referral

systern. Individual institutions, programmes and resources were developed, along with a process of

coordination. This was due to international development assistance, directed towards Palestinian

projects, which increased substantially at the time of the Intifada. Money and resources, given

primanly by European governments and NGOs in response to the disability needs of the

Intihda-injureci, supported the creation, operation and expansion of secondary and tertiav

rehabilitation facilities. These institutional services were established in the central area, in the

cities of Jenisalem, Bethlehem and RamaIlah. UPMRC CBR workers noted that they relied heavily

upon these institutions for referrals, because this supported Palestinian facilities, and because the

quality of service was high.

The govemment of Swveden was a particularly responsive international actor, supporting

rehabilitation through the Swedish NGO Diakonia. A CBR advisor explained how political

circumstances created the background for rehabilitation enorts:

Diakonia came to this country to support the building of the Abu Rayya Rehabilitation Centre, in 1989 as a response to the [Swedish] foreign minister and his visit here and the big problems with the Intifada. Later on therc were several initiatives by diffcrent NGOs to stan some CBR activities and pilot things here that are more on the cornrnunity level, and try to find out what is the CBR model for us. Diakonia expressed interest to support that.

Diakonia went on to provide technical, financial and logistial support towards the organization of

the CNCR and regional CBR projects.

In addition to international support, other aspects of the Intifada ûiso encouragcd the

refenal element of CBR. Thc high profile of the Intifada-injured was said to have provided a

mutual cause for local and outside organizations, which clicited the cwperation necessary to create

a rehabilitation system. The spirit and structures of Intifada cornmunity resistancc also facilitated

formal cooperation in CBR.

4.3.3.8.3 CBR programme responses - Contribution to an infrastructure

UPMRC's response to the jack of rehabilitation services provided under Occupation was an

aspect of its community resistance activity. To compensate for the lack of a Palestinian

government, and to meet the increased disability needs of the Intifada-injured, UPMRC and other

NGOs and medical organizations took the initiative to mate and coordinate services. UPMRC

contributed to the nehvork of services through its CBR tearns, as well as through rnedical and

physiotherapy c h i c facilities. Links establishd within the CNCR allowed for the development of

a referral neh~cirk, which was being created with international support.

On a practicd level, CBR workers were required to respond to the travel restrictions that

impeded the r e f e d system. CBR workers expanded their duties beyond rehabilitation, providing

transportation for individuals to health institutions and medical specialists when essential. A CBR

worker reporteci, 'We take a patient ounelves, in our own cars. Because it's easier for a woman in

a yellow-plate4 car. But it's difficult - we're not supposed to do it. It's not in CBR, but, to get

things done, especially in cases that really need it, we do it."

4.3.3.8.4 Sumrnary

Conditions of repression were formidable obstacles to a rehabilitation refeml system,

mostly through creating barriers to access through restricted travel. On the other hand, resistance

conditions, particularly international development support, were largely responsible for the

evolution of a functioning refenal system. Political solidarity elicited needed extemal support and

intemal cooperation for a referral system, though one that remained vulnerable to obstacles of the

Occupation.

4.3.4 Political Violence and CBR: Summaw of Findings

The case of UPMRC shows clearly that CBR was affected by the political conditions of

repression and resistance. Some conditions were more important than others, and the elements of

CBR were affected in different ways, and to varying degrees.

The principle conditions of repression to affect the development of CBR were travel

restrictions, administrative bamers upheld by requiring IDs and permissions, and the lack of self-

govemance and econornic implications of military administration. The most important conditions

of resistance were non-violent cornmunity resistance, the status and synbolisrn of the Intifada-

injured, and international development assistance to Palestinian rehabilitation programmes. Thus,

confiict conditions had an influence in both hindering and helping CBR. Overall, however, the

repressive conditions were detrimental towards CBR, and resistance conditions were facilitatory.

In addition, the individual elernents of CBR were affected to diffcrent dçgrces. Some

elernents were strongly affected by the conditions of conflict. These includcd attitudes towards

disability, integration of disabled people, cornmunity involvernent in the CBR programme, and the

development of a referral network. Other elernents were less affected, such as the modei of

partnership among participants, and provision of participant-directed services. Not surprisingly,

some elernents were affectcd both negatively and positively. For example, community involvement

in CBR was strongli, inhibited by rcpressive conditions, but strongly positivcly affccted by

resistance conditions. Thc element of training was not significantly affccted, and the ovcrall effiect

upon the element of local tcchnology wvas neither clearly positive nor negativc.

Overall, UPMRC undcrtook effective responses to the conditions of political violence.

CBR workers took pridc in thcir rcsourcefulncss in ovcrcoming travel restrictions. In the face of

insurnountable obstacles (such as those imposed by military administration, economic factors and

administrative barriers), the programme used innovative tactics which addressed CBR concems

using alternative mcthods, such as strengthcning Palestinian institutions likc the CNCR and the

GUPD. Important in this regard c s i s that UPMRC was effective in complemcnting its local

community efforts with initiatives at the highcr organizational level.

As well as responding to the dificult political conditions, the CBR programme took

advantage of the positive cffects officred by non-violent community resistance and international

support. Concem for the Intifada-cases was balanced with a broader focus on disability issues, de-

ernphasizing the popular focus on youthfùl heroes.

TU understand why CBR elernents were affected differently, aiid how the UPMRC CBR

programme was appropriate to conditions of political violence, CBR can be viewcd fiom a

comrnu~ty development perspective. Such an approach addresses capacities and vulnerabilities of

a comunity dunng time of codict.

CHAPTER S

DISCUSSION

5.1 Design Issues and Study Limitations

The qualitative case study design was appropriate to this investigation, howvevcr thcre werc

some inevitable dificulties in defining boundàries of the case. For example, UPMRC's CBR

programme was not a hornogenous or stable entity. As the Intifada progressed and as CBR models

bewne more well known and desired, the programme undenvent transformation. This change

provided a challenge to some rcspondents in surnmarizing their expenence of CBR over the yean.

Also, one of the CBR projects was implemented in partnenhip with another NGO, which made the

UPMRC programmatic boundary less dcfined.

Limitations of the study included the language diffcrence bchveen rcsearcher and

rcspondents. The rescarcher had a basic understanding of Arabic, and many rcspondcnts were

highly cornpetcnt in English. When requircd, Arabid English interprctcrs werc used, choscn on the

b a i s of their ability, thcir fdmiliarity wvith the programme, and the comfon of the interviewee. The

interpreters were UPMRC collcagucs of CBR workcr rcspondents, and volunteercd their services.

Despite these factors, some depth of meaning \vas likely lost, both in the cases of intcrpretation and

when rclying upon the flucncy of respondcnts who spoke English as a second language.

A second study limitation was that data analysis did not commencc until data collection

was complete. Analysis could have beguii and proceeded concurrently with interviews, in order for

interviews to be more responsive to emer~ing categorics and themes. However, the researcher

chose to sacrifice flexibility for the sake of consistency of data collection technique.

5.2 Discussion of Findings

ln order to discover whether CBR is an appropriate rehabilitation response under

conditions of political violence, 1 have desctibed the w e of a Palestinian NGO that developed a

CBR programme within such a situation. Not surprisingly, findings showed that the conflict

conditions did affect CBR, that some of the conflict conditions had greater impact than others, and

that individual clements of CBR wcre affected differently. Some questions, however, are r a i d :

Why did resistance conditions actually facilitate CBR, and facilitate certain elemcnts in particular?

In addition, how can CBR programme rcsponses be assessed for their appropriatcncss under such

conditions?

In answenng these questions, CBR is considercd outside the sphere of rehabilitation

medicine, and vicwed fiom the perspective of community developrnent . UPM RC's CBR

programme was orientcd beyond service provision, towards comunity dcvcloprncnt, in ordcr to be

most relevant and responsive to prevailing circumstanccs.

This discussion presents the central idea of CBR as community developrnent. by

reintroducing Anderson and Woodrow's tenet that assistance in conditions of conflict must

contribute to, and not undermine, community dcvclopment. Their concepts and analflical

fiamework will be used to expiain the significance of the findings in the case of CBR. UPMRC's

CBR programme, implcmented as a fonn of assistance under conditions of political violence, will

illustrate Anderson and Woodrow's critcria for an appropnate response, through the organization's

developrnental focus. The discussion will conclude by offering perspectives for agencies wishing to

pursue CBR in conditions of conflict.

5.2.1 The Realms of Comrnunitv: Understandinn CBR and the Tritifada

Why did resistans conditions actuaily facilitate C B S and certain elements of CBR in

particular? The answer lies in observing what the Intifada specifically offered CBR, in. texms of a

supportive environment.

As introduced in Chapter Two, Anderson and Woodrow (1989) assert that any assistance

made to cornmunities living in confiict must not simply provide relief, but must contribute to long-

term development. In order to be developmental, the assistance must respond to esisting comrnunity

capacities and vulnerabilities, strengthening the former, and reducing the latter. Accordingly,

comrnunity capacities and vulnerabilities cm be divided into three categories, or realms:

physicalfmaterial, socia~organizational, and motivationaVattitudinal. Anderson and Woodrow's

(1989) Capacities and Vulnerabilities Analysis (CVA) incorporates these realms into planning and

evaluation of programmes which assist communities dçaling with emergcncies of conflict or

disaster.

Before esamining the CVA frarnework itself, the three realms - physical, social and

attitudinal - can be considered in a wider sensc. Anderson and Woodrow have provided guidelines

for defining the three realms (see Appendix L), noting that the categories are neither discrete nor

exclusive. A conceptual application of these realms provides insight into the rclationship between

conflict conditions and CBR. Following the guidelines of Anderson and Woodrow, 1 have

categorized the CBR elements into realms, as shown in Table 5.1.

Table 5.1 CBR Elements as Realms of Community

CBR element CVA realm I attitudes attitudinal / motivational 1

srnial / organizational attitudinal/ motivational

training physical 1 material 1

part icipant-dirccted services social l organizational

cornmunity participation social / organizational

partnershi p attitudinal / motivational

technology physicai / material 1 referral network social / organizational

physical 1 rnaterial

The above table shows that the CBR elements arc reflected in al1 three realms, indicating that a

broad CBR programme may address physical, social and attitudinal aspects of community. In

addition, the table allows us to more carefùlly consider four important elements, Le. those elements

that were noted to be most strongly affected by conflict conditions. As noied in the surnmary of the

study findings, the important elements of CBR in this study were:

- promoting positive community attitudes, - promoting intepration of people with disabilities, - implementing with community participation, and - participating in a referral network.

It is remarkable that these elements of CBR were strongly facilitated by resistance

conditions. From the literature, it was expected that social and health programmes wouid suffer

under conflict conditions, and indeed repressive conditions did exert negative effects. Table 5.1,

however, illustrates that these four elements largely reflect attitudinailrnotivational and

sociaVorganizationa1 realms of conununity. These four CBR elements were positively affectai by

resistance conditions because the Intifada itself was an event of collective motivation and

organization.

The Intifada grcw from a widespread popular resistance movement. The "national

movement" was supported by "mass organizations," especially of women, workers, students and

youth (Taraki, 1990; Hiltermann, 199 1). Their activities were political, social and cultural, and

politically afiliatcd cornmittees also undertook medical and agrkul~ral relief work. The Intifada

itself spawned popular committees (ncighbourhood cornmittees), whose volunteers provided and

coordinated education, hcalth, food storage, agriculture and security for the community (Nassar &

Heacock, 1990). Taraki dcscribcs these collective actions as the development of political

consciousness arnong Palestinians, while Nassar and Heacock speak of the revolutionary

transformation of Palestinians. Clcarly, anihidina! and social factors reinforced one anothcr.

National identity was assencd and strengthcned through community mobilimtion and organization,

demonstrating how '.i community cm build community cohesion through joint action" (Anderson

& W d r o w 1989, p. 14).

Consistent with documentation on the Intifada, the current study of UPMRC CBR revealed

that resistance conditions were primarily expressions of the attitudinal and social rcalrns of

community. An important example, as noted earlicr, were the Intifada-injured, who were not

simply individuals with wounds. Thosc who bccarne permanently disablcd werc heroes of the entire

community, synbolizing Palcstinian rcsistance since "disability \vas conceptualized as martyrdom"

(Atshan, 1997, p. 5 5). The emotions that the Intifada-injured elicited fiom Palestinians included

pnde, anger, and sadncss. It is essential to appreciate that these emotions were expenenced

collectively as w c l l as individunlly, with grcat intensity because Palestinians considcred the injured

to be their childrcn and brothers. These emotions catalyzcd collective and individual action that

resulted in violent and non-violcnt resistance to Occupation. Non-violent resistance activities, such

as rnass demonstrations, strikes, and the development of new responsive organizational structures

with non-traditional leaders, uicreased social cohesion and a sense of national identity among

community members. Such a 'comrnunity-building' environment in turn supported the .

development of elernents of CBR h t require attinidinal and social change. Within this politicized,

energetic and supportive environment, social change was pro-active and rapid. Thus, CBR as an

innovat ive and practical concept for rehabilitation emerged and flou rished not onl y during the

Intifada, but because of the Intifada.

IIhis is not to Say that physical factors were unimportant. Indeed, the significant economic

impact of Occupation was stressed by respondents, and has been the subject of much study (e.g.,

GrahamBrown, 1986; Heiberg & Ovensen, 1994; Roy, 1995; Saleh, 1990; see also UNCTAD,

1993; World Bank, 1993). There were grave econornic impacts on the Pôlestinians frorn Israeli

controt of such material factors as land, water, investment, trade and taxicion. But development

and underdevclopment are more than issues of economic growth or stagnation. In her pivotal work

in the Palestinian context, Sara Roy (1995) emphasizes the political, social and cultural aspects of

development, and she proposes a theory of dedevelopment to descnbe the result to Palestinians of

Israeli policies of occupation. Differentiated fiom underdevelopment, dedevelopment "not only

distorts development but forestalls it entirely, by depriving or ridding the economy of its capacity

and potential for rational structural transformation and preventing the emergence of any self-

correcting rneasures" @. 128, whereas underdevelopment allows for "needed structural change

within the weaker penpheral entity, although that change is disarticulateci, onented to, and shaped

by the expansion of the dominant extemal economy to which it is subordinate." p. 129). Israeli

policies that have resulted in Palestinian dedevelopment include expropriation, dispossession, and

deinstitutionalisation, and "were designed to secure military, political, and economic control over

Gaza and the West Bank, and to protect Israel's national interests" (p. 135; see also Benveniai,

1984). Roy's research makes clear that econornic impacts, though rnatenal, arose fiom lsraeli

social and ideological factors. Similarly, Palestinian resistance to occupation was not priniarily a

response to econornic hardship. As Saleh (1990) atteN, "The essence of the conflict between the

Palestinians and the occupation is, however, not economic but political" (p. 48).

Anderson and Woodrow note that most assistance in conflict and disasters is concentrated

upon physical ne& of the so-called "viaims," because it is material suffering that compels

outsiders to act. However, in t e m of providing assistance that will contribute to, and not

undennine long-tenn community development, they Say that "experience shows that it [the physical

1 matenal realmj is often iess important than the other two areas" (p. 13). Similarly, findings of the

current case study show that the CBR elements of the physicaUmatenal rcalm - training and

technology in particular - were affected to some degree by the conflict conditions, but their

development proceeded without overall hindrance or help from the conflict. This suggests that

lirniting CBR assistance to the provision of material rehabilitation services would bc shortsighted,

as this would demonstrate an understanding of community only in terms of its physical realrn.

In sumrnary, two key aspects of the Uprising - collective action and the Intifada-injured -

directly underlay two key elements of Palestinian CBR - community participation and

transforrning attitudes towards disability. Resistance conditions of the Intifada facilitated CBR by

providing a dynamic community environment of organizational and motit ational strength. The

organizational and motivational elements of CBR grew, and benefitted the most, fiom the unified

action and common purpose that charactenzed this environment.

Political motivations of the Intifada led to actions that ubimately promoted cornmunity

development. It will be seen (Section 5.2.3.) that a poiiticited and community development

approach to health, dernonstrated by the primary health care initiatives of UPMRC, infiuenced

rehabilitation efforts, with CBR emerging as a stmng choice of health activists. Yet Anderson and

Woodrow contend that supporthg community development specifically involves increasing

capacities and reducing wlnerabilities. The UPMRC case can now be examined to see how CBR

ftlfilled these criteria.

5.2.2 Ca~acities and Vulnerabilities. and the UPMRC Response

How cm CBR programme responses be assessed for their appropriatencss under

conditions of political violence? The CVA framework was developed for use within situations of

disaster or conflict, as a tool for programme planning, implementation and cvaluation (Anderson 8;

Woodrow 1989). The fmcwork was derived from the experience of both local and international

NGOs, and thc current UPMRC case provides an example of the use of this framcwork for CBR

programmes .

Findings of the UPMRC case study exposed a variety of comrnunity capacities and

vulnerabilities, which crncrged from both contestual factors and political conditions. The following

tables sumrnarize study findings, showing the most important capacities and wlncnbiliiies, and

indicate how Palcstinian dcvclopmcnt of CBR can be piciured within Anderson and Woodrow's

CVA h e w o r k .

Table 5.3 Vulnerabilities in Palestine for the Development of CBR

physical / mate rial

Type of influence 1 Vuinerability

I

regional factors i Economic underdevelopment and poverty were characteristic of rural areas.

1

I

professionalization and i Shelten and institutions were considered the : appropriate place for people with disabilities. institutionalization of 1

disability / cultural factors j Therc were few rehabilitation institutions i offering adequate, high quality senices. I

repressive conditions i Physical impositions included: travel : restrictions, economic under- and de- i development, administrative bamers through i system of permissions, lack of self-govcmance, i lack of health and rehabilitation facilities, i I collective punishment, military actions. I .

resistance conditions i Violcnt resistance activities caused disruption. I

i There was a rise in the nurnber of injured and i disabled people. International relief that was i characterized by donations fostcred dependence.

social / organizational

cultural factors i Large nuclear fmilics strcsscd mothcrs caring i for disabled members. Charity to people with i disabilities undermined their estecm and power. I

i Authoritarian, hierarchical and conscrvative i culture w s inflexible with respect to new approaches and roles for disabled persons.

8 1 I

professionalization and i Authority and control in rehabilitation lay in the institutional izat ion of i hands of nondisablcd people. disability

I

1

,

resistance conditions i , Factionalism hindered fùll cooperation in i community activism. 1 l 8 I

I attitudes motivational i Underlying attitudes towards people with i disabilities were negative and pityng.

Thcse tables illustrate that Palestinian society demonstnted both capacities and

vulnerabilities for addressing disability needs. These capacities and vulnerabilities were influenced

by contextual factors as well as by the conditions of political violence. Not surprisingly, some

factors were not solely positive or solely negative. For example, the fact that there were available

skilled rehabilitation personnel, and that professionals controlled disability initiatives, indicates

both a capacity and a vulnerability. It is within this cornplex scenario of capacities and

wherabilities that the appropriateness of CBR programme responses is demonstrated.

Assistance provided during conflict risks increasing the wlncrabilities and ignoring, if not

undermining, the capacities of the people (Anderson & Woodrow, 1989). A CBR programme is

equally susceptible to this danger, and would be considered an inappropriate response to the

conditions if it did so. The WMRC CBR programme, implernented under conflict conditions,

illustrates how the Anderson and Woodrow criteria can be applied. Responses of the CBR

programme to the capacities and vulnerabilities presented by both contextual and conflict

conditions are appropriate in that they promote long-tcnn community devclopment by working to

increase the capacities and rcduce the wlncrabilitics.

The CBR programme increased observed capacities in a number of w y s . It expandcd

available rehabilitation skills, by sponsoring university physiotherapy studcnts and training

rehabilitation workers. It cooperated with international partners, guiding resources towards

community rehabilitation needs. It worked within the supponive farnily structure. Finally, it

panicipated iri the non-violent community resistance movement, using the Intifada to catalyze

positive change for people with disabilities.

By its very nature, CBR directly addresseci many of the vulnerabilities that were observed

to aise fiom contextual factors. For example, it provided rehabilitation services that were

appropriate to poor areas, offered an alternative to institutionalized care and the charitable

approach, promotcd positive atîitudes towards disability, and put greater control of disability issues

in the han& of community members.

In addressing vulnerabilities arising fiom repression and resistance conditions, the CBR

workers and the UPMRC programme relied heavily upon communil knowledge and community

interaction. The UPMRC response balanceâ participants' needs, accounted for political

sensitivities, mdified community rnodels and approachcs, and overcame logistical obstacles

through innovation. While many physical vulncrabilities were insurnountable, responses utilized

strengths dcrived fiom social and attitudinal capacities.

In sumrnary, UPMRC put a community development philosophy of CBR into action. In

doing so, the Anderson and Woodrow CVA h e w o r k provides an illustration of how CBR

programme responses can be assessed for their appropriateness undcr conflict conditions. The

CVA ftamework would be a uscful tool for CBR, to guide the incorporation of comrnunity

development goals into programrne planning, irnplerncntation and evaluation. In the planning

phase, an outline of existing capacities and vulnerabilities could be cstablished through observation

and consultation, and disaggregated for certain community groups, such as people with disabilitics

or women. Specific means of incrcasing those capacities and reducing the vulnerabilities would be

proposed, and undertaken within programme implçmentation. Indicators of programme

effectivcness would incorporate these factors for cvaluation. The frarnework has the advantages of

being easy to use, of leading to apprcciation of capacities, and of allowing uscrs to discem and

weigh factors of conflict and contcst. Thc CVA fiameivork was not creatçd for CBR, but its

flexibility would allow it to be applicd to such a rehabilitation programme.

5 2 . 3 COmnunihf Deveio~rnent as Politicai Action

In many ways, Palestinian community development efforts were the by-product of a

political process. At the outset, UPMRC did not set out to develop a CBR progranmq. However,

as the Intifada continued, UPMRC and other NGO sector activists dçveloped CBR as a preferred

method for rehabilitation initiatives. Yet it is clear that UPMRC's choicc of CBR had wider

implications than simply finding a solution to the crisis of increasing disability. Within the

Palestinian context, health and rehabilitation issues were politicized, as were al1 social issues.

Primary health care had emcrged within the context of political resistance, and as a component of it

(Barghouthi & Giacaman, 1990). But the goal was more far-reaching than simply ending

Occupation. Building a civil society based upon national identity was considercd nccessary to

actors such as UPMRC (Barghouthi, 1994). Also, as noted early in the Intifada, "...the

Paiestinian hcalth agenda must reflect the social content of the Palestinian aruggle - both to

liberatc the nation and to build an equitable society where good health and access to health care are

a fiindamental human right" (Barghouthi & Giacaman, 1990, p. 84).

As in their work promoting primaiy health m e , WMRC's community dcveloprnent

approach to CBR was directly anributable to the prcvailing political and social situation. The

CBR programme of UPMRC has been considered an exemplary mode1 of social development,

particularly in tems of gendcr issues, and UPMRC itsclf has been terrned a "new social

movement" (Craissati, 1996). At a 1992 UPMRC-sponsored confcrence, CBR was discussed in

tems of working with disabled people to bbchallenge the injustices within al1 sectors of society,

working as part of the struggle to forge a more equitable structure" (International People's Health

Council, 1995, p. 127). The title of the conference report makes UPMRC's political focus explicit:

"The Concept of Health Undcr National Dcmocratic Struggle." A politicized CBR philosophy

serve- to re-orient the prc-existing perspective towards disability, and UPMRC saw CBR as

involving both service provision and action for social change, in order to meet both short- and long-

tenn disability needs .

5.2.4 Conflict and Deveio~ment - a Place for CBR

As was noted in Chapter Two, Anderson and Woodrow's Capacity and Vulnerabilities

Analysis has been widely cited and applied. With very practical implications, the Oxfam

Handbook for Development and Relief highlights sociaVorganizationa1 and motivationaVattitudinai

elements within their principles of response to emergcncy, and also goes as far as to Say:

Both relief and development should be more concemed with increasing local capacities and reducing vulnerabilities than with providing goods, serviccs or technical assistance. In fact goods, seMces etc should be provided only insofar as they support sustainable developmcnt by increasing local capacities and reducing vulnerabilities. (Eade & Williams, 1995, p. 834).

This Oxfam programming principlc not only articulates the CVA, but also parallels the Paleainian

principlc for health development during the Intifada, in which UPMRC and othcr health activists

promoted a "politicaUsocia1 health alternative" (Barghouthi & Giacaman, 1990, p. 8 1) that relied

on the strengths of votuntarism and health education, "in contrast to the potvcr of money,

equiprnent and buildings" (pp. 79-80). This principle echoes the findings of the current UPMRC

case study, which suggest a reduced emphasis on physical elements of CBK in prefercnce for

social and attitudinal ones,

Within the few welldocumcnted programmes of CBR within situations of conilict, a

community development focus is apparent. Peat et al. (1997) outline specific benefits resulting

frorn the integration of disability issues and CBR into a peace-building process, citing 'relief

development' as a policy principle which envisions building the capacity of local NGOs who

undertake CBR during conflict. O x h UK and Ireland provide in-depth selfevaiuative

documentation of their work with disabled children in Bosnia (Hastie, 1997). This Oxfam

casebook explores concrete issues for development and disability work under conflict conditions,

such as flexibiiity, ftnding and legal status, retention of stafF, insecurity and danger, and

communications and transport. More recentiy, Boyce's evaluation of a C BR programme in

Afghamstan details how rehabilitation service provision can be successfully integrated within

explicit development objectives and strategies, despite the obstacles and risks posed by war (Boyce,

1998). As yet, however, there is no evidence of the Capacities and Vulnerabilities Analysis being

applied to CBR programrning.

Remarkably, the Odarn experience in Bosnia echoes some of the findings of the current

Palestinian study, such as the opportunity presented for positive social change. Hastiç (1997)

quotes an Oxfam staff pcrson as saying, "It seems that it is not only possible to work on social

development projects in an unstable society, but also that unstable societies somctimes provide the

necessary conditions of shift and change to allow the adoption of new modcls, such ris the social

mode1 of disability." (p. 93). This was also obsewed in Lebanon, where the war had positive

results for disabiIity a\varcncss, for innovative projects such as CBR, and for coopcntive action

between disability professionals and people with disabilities (Abou Khali 1, 1997). In these cases,

international support to local groups \vas vital in prornoting social change, as was also scen in this

Palestinian CBR study.

Community based rehabilitôiion programmes have been classificd according to scveral

models (e.g., Kisanji, 1993: McColl & Paterson, 1995; see also Peat, 1997, pp. 48-7 l), and one is

a mode1 which articulates "CBR as part of cornmunity development" (Wu, 1997; sec also

Chaudhury et al., 1995, p. 177; Peat, 1997, p. 22). This parallels the definition of CBR as "a

strategy within cornmunity deve1opmcnt" stated jointly by the ILO, UNESCO and WHO (1994).

Coleridge (1993) makes an important contribution by locating CBR within a ethical and practical

discussion of disability in terms of concems for liberation and development. However, Coleridge

also daims that there is a muddied understanding of what CBR entails. Ambiguity and jargon are

demonstrated by the term 'CBR' itself, which "has tended to become synonpous with 'disability

work in development"' (p. 90). Indeed, though the issue of community development is increasingly

addresse. by CBR advmates, there appean to be confusion within CBR literature regarding what

it entails. Comrnunity development is often understd more nanowly as comrnunity participation

(participation being an important, closely related, but distinct issue) or with a Western bias as

personal empowement. Certainly it is essential to strengthen the capacities and diminish the

wlnerabilities of individuals, or the individual members of certain groups. Rehabilitation has

worked towards this goal within a medical model of disability. For CBR Anderson and

Woodrow's analysis is usehl for its focus on comrnuniîy level of analysis and intervention. It also

prompts CBR plannen O identiQ capacities and winerabilities beyond the physical.

5.3 Conclusion and Implications

1s CBR is an appropriate rchabilitation response under conditions of political violence?

This study suggests that it can be, if 'appropriateness' is understood in ternis of contribution to

community development. However, 1 suggest that CBR be chosen and irnplemented in those

situations with care. This Palestinian case study showved that CBR was afected both positively

and negatively by two distinct types of political violence, and that the individual elements of CBR

were affected in diffcrent ways. nie smdy also demonstrated the importance of contextual factors

that are beyond the sphere of the confiict. Therefore, if one believes that assistance should not

undermine cornmwlity development, it would be critical to assess several factors before endorsing a

CBR initiative in a region of conflict. These factors would include the comrnunity capacities and

vulnerabilities, the type of conflict, contextual factors such as culture, and whether certain elements

of CBR are to be priontizeâ in the particular project. The findings of this study indicate that,

where sociaUorganizational and attitudinaVmotivational capacities are high, a CBR programme

with a comrnunity development approach can be successfûlly developed.

While a strength of Anderson and Woodrow's framework for developmental relief is that it

allows flexibility for many models of programme intervention, nonetheless, suppon for long-term

cornrnunity development remains a desird goal. If a CBR initiative thoroughly assesses, and then

maximizes capacities and reduces vulnerabiiities, then it will have the characteristics of a

community development approach. Othenvise, and certainly under conflict conditions, there

remains a high nsk of addressing only highly-visible imrnediate needs while undermining

community strengths. At the samc time, Anderson and Woodrow point to the importance of

disaggregating community groups (on the basis of gender, class and age, for example) when using

the CVA framework. It seems seIf-evident that a CBR programme be intended, above all, to

benefit people with disabilities. Therefore, a programme should explicitl y promotc their

development, and can evaluate itself for this goal.

This midy of the UPMRC CBR programme provides a unique and exernplary case

(Patton, 1990). This case study did not seck to compare the effectiveness of cornmunity-bascd

venus institutional initiatives in working towards goals of promoting disabled pcrsons'

development, of fostcring cornmunity development in general, or of reducing conflict. Within

disability and rchabiiitation ficlds, therc is growing reco~nition of thc necessity for coordinated

action on the pan of community-based groups with institutional and professional actors, each

exhibiting their oivn particular strengths, in ordcr to make maximum gains. Nonetheless, while a

rehabilitation initiative may be considercd to make appropriate responses to certain conditions, it

would be most enlightening for both community and institutional rchabilitation progranunes to be

critically evaluated by people with disabilities, in tems of their o m participation and needs.

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APPENDIX 1.

CAPACITIES AND VULNERABILITIES ANALYSIS

(adapted fiom: Anderson and Woodrow, 1989; Anderson, 1994a)

The CVA framework distinguishes h e e realms of capacities and vulnerabilities. These are:

Physicd / Material: these include features of the land, climate and environment, people's health, skills and labour, infrastmcture, bousing, technologies, water and food supply, physical technologies, capital and other assets.

Social 1 Organizationd: this refers to the social fàbric of a population or group, and includes stnictures like fàmilia and kinship groups such as clans, social and political organizations, and synm>s for diaributing goods and services. It therefore includes forma1 and informal system through which people get things done, such as making decisions, establishing leadership, or organizing various social and economic activities.

Motivationai / Attitudinal: these include cultural and psychological factors that may be based on religion, history, and expectations. It reflects how the community views ifself, including its beliefs, motivations, and sense of empowerment or dependency.

The three realms of vulnerabilities and capacities are represented in the matrix. n i e analysis always refers to factors at the community level, rather than at the individual level. The intemal lines in the matrix are dotted because the categories overlap and there is constant interaction among them.

Vulnerabilities Capacities

What productive resources, skills, and hazards exist?

Social / Organizational

What are the relations and organization among people?

Motivational / Attitudinal

How does the community view its ability to create change?

APPEND lx II.

INTERVIEW QUESTION GUIDE

Questions were based on a set of eight 'elements' in CBR developed for this study.

Note to respondents: the ternis "Occupation" and "Uprising" refer to the conditions of confiict in which you lived and worked (for example, curfcws or strikes, violence, threats).

Romoting posif ive community attitudes towards disability and people with disabiliries What have been the gcneral attitudes (and behaviours) totvards disabled people?

positive / negative / charitable ... * how did the Occupation / Uprising affect these?

To what degrec has this program influenced attitudes towards disability? * how 1 why not? * reasons for effectiveness / little effectiveness?

Romoting in tepration of people ivith disa bilities with in society How do you think thc Occupation / Uprising affected people with disabilities in being fully active and involved within society?

no cffcct / made easier / made more dificult? To what degrec has this prognnl enabled pcople with disabilitics to takc part in society?

how / why not? * rcasons for cffectiveness / little effcctivcness?

Tramferring rchabili~a f ion kn oivlcdge and skills (trainin@ In gencral, to what degree are pcople with disabilities and their familics becoming educatcd, and lcarning the skiils to takc care of thcmselves?

* how / why not? * did the Occupation i Uprising affect this? How?

How has this proçram woked ro educate and teach self-lirlp skills? rçasons for effectivcncss / little effectiveness?

Roviding particim~nt-rlirected rehabilitation services To what dcgree have people with disabilities and their families havc bccn involvcd with making decisions about this program's rehabilitation services, so that scrvices are based upon their ow expressed needs?

* how / why not? how did the Occupation / Uprising affect this?

Implcrnenthg the programme ivith cornmunit 11 nartici~ation To what degree has the community bccn involvcd with this program in: making decisions, running the program, taking responsibility? (decision-mnking. implementation, itcco~rntcrbiliry)

how / why not? how did the Occupation / Upnsing affect this?

$ Erliibiting a model of partnershin among people with dimbilliies, families, the community, and reh ttbilitation personnel To what degree have people with disabilities, their families, the communitv, and rehabilitation workers cooperated and worked together as partners?

how / why not? how did the Occupation 1 Upnsing affect this?

Usimg locaIIpmade rehabilifation aids and equipment (iechnnlom) To what degree were local matenals and workers used to make rehabilitation equipmentfaids?

+ how / why not? how ddi the Occupation 1 Uprising affect this?

b Participating in a referral nehvork luith specialists and institutions, fior professions/ and tech nical reh u b i h t i o n supporî To what dcgrce did the communig program coordinatc with, and refer to, an outside network of professiomls and institutions for treamienil trainingkquipment?

* how / why not? how did the Occupation / Uprising affect this?

also: Would you like to add any othcr elcments of Cornrnunity Based Rehabilitation bat may not havc been mcntioncd?

Overall, do you feel that Cornmunity Bascd Rehabilitation works well in the conditions of the Occupation and Uprising?

OTHER DATA COLLECTION:

Document rcview, and intcrvicws with representatives of the UPMRC, elaborated upon: i) the history of the UPMRC rehabilitation programme ii) thc structure of the programme iii) programme mandate and act ivities iv) obstacles and programme strategies v) programme rcsources and support

APPENDIX III.

DATA ANALYSIS TOOLS

1. Process Diagram

Conditions CBR elements

occ

Int Train C- efficcts

upon

Programme responses

2. Sample Codes

Background back.cult back. reg back.prof back.att

Conditions cond. occ

cond.occ.miladmin cond.occ.popdis cond.occ.adminbam cond.occ. policies cond.occ.milact

cond.int cond.int.non-v cond.int.viol cond.int.injured cont.int.support

Work work. rep work.res

Int int.effects int.effects. rep int.efficcts.int int.responses

Contextual or background factors culture regionuf & comrnunity characteristics profesionulization / insfifutionalizaiion' of disability attitudes rowards disability

Conditions of political violence Occupation (conditions of repression) military administration population dislocation administrative barriers policies of control and punishment military actions Inti fada (conditions of rais f ance) non-violent communiîy resistance violent resislance actions inrifada-injured internafionaf support

EfJects of conditions on dailv activities of CBR W S E'ects of occupu fion Eflecis of inttjada

CBR Elerncnt: prornoting +ve uttitiides Eflccts a/conditions on elernent of artirudes Eflccts of ocaipotion Efïcts of inrifada CBR program responscs

CBi? Elment: integration Efecn of conditions on elemcnr of integration Effccrs of ocnipotion Effccts of inrifada CBR program responses

... [Train ... Serv ... Comm ... Pa R... Tech ... Refl

Activities CBR program aclhlities

3. Matrix summarizing findings and noting processes

1 . attitudes

1 2. integration

1 3. training 4. bencficianes

direct services

5 . community involvement

6. partnership

17. technology

OCCUPATION CONDITIONS, UPRISMG CONDITIONS, having : having : negativc effects Positive effects Ncgative effects poSitive effects

1

i IS, r

KEY:

OCCüP ATION Conditions UPRISMG Conditions

A... Miiitary administration P.. . Policics of occupation

and punishment M... Military actions B... Administrative barriers

W.. . Violent resistancc CR.. . Non-violent comrnunity resistance 1.. . Intifada-injurcd S . . International support

@rackets) indicate a less sipificant effiect

arong indication of relationship (Occupation -ve I Intifada +ve)

[/ moderate indication of relaiionrhip

-1 no indication of relatiowhip

APPENDTX IV.

INFORMATION AND CONSENT FORM

TlTLE OF PROJECT: Community B a d Rehabilitation Under Conditions of Political Violence - A Case Study of the Union of Palestinian Medical Relief Committees

RESEARCHER: Sandra Ballantyne BSc.(PT), MSc candidate Queen's University, Kingston, Cana& O1 1-6 13-545-6 103

ACADEMIC ADMSOR: Professor Will Boyce School of Rehabilitation Therapy, Queen's University O1 1-613-545-6726

Dircctor of School of Rehabilitation Therapy: Dr. Malcolm Peat 0 1 1-6 13-545-6 1 O4

You are being asked to participate in a research project to descnbe the community bascd rehabilitation program of the Union of Palestinian Medical Relief Committees (UPMRC). The purpose of this study is to understand how community based rehabilitation is provideâ in circumstances of political violence. nie researcher will read through this consent form with you, and answer any questions you rnay have.

You will be interviewed by the researcher one or bvo times, each interview lasting approximately one and a half hours. During these i n t c ~ e w s you will be asked questions about how the conditions of the Uprising affectcd rehabilitation of people with disabilities, and how the UPMRC program worked undcr these conditions. The interviews will be tapcd, and these tapes will not be shared with anyone else. The rcscarcher will type thcse conversations for use, and thcn the tapes will be erased. The wvrinen pages of the interviews will be kept without your name attached. The information will be kept in a locked location, and only the researcher will have access. The final report, wvith anonymous quotations, \ d l be sent to the UPMRC at the end of the snidy, and everyonc wvho was interviewed will be notified that the report is available.

This study will not be of direct benefit to you, but others in situations like yours may benefit fiom your description of your experiences. Due to political sensitivities, you rnay be at some risk, as information about activities during the Uprising will be shared. If you decide not to continue with the study, you may stop at any time.

1 have read and understand this consent form. 1 have been given time to consider it, and get advice. By signing this form, 1, , agree to participate in this study. 1 understand the information may be published, but that my name will not be associated with the research. I understand that 1 rnay choose to not answr any specific question, and 1 may withdraw at any the . Al1 of my questions have been answered to my satisfaction. 1 will receive a copy of this consent f o m for my information.

participant \r i tness researcher date