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Starting from scratch - The ICRC orthopaedic project in Afghanistan

28-11-2002 by Alberto Cairo

In Afghanistan, disabled people need a lot more than a plastic leg, or to learn to walk. They need help with schooling, and a job; or perhaps a loan to start up a small business. Difficult - but possible.

For the past 13 years an Italian physiotherapist, Alberto Cairo, has offered hope and care to war amputees and the disabled of Afghanistan. In charge of the ICRC's orthopaedic programme, he leads a dedicated team fitting hundreds of artificial limbs each month. Some extracts from his journal.

From Alberto Cairo's diary 
ICRC/S. Conlan ref. AF-E-00071
Alberto Cairo, head of the Kabul orthopaedic project, Jan. 2002 


With the passage of time, our Afghanistan orthopaedic project has changed quite a bit. We now have six centres, which provide social reintegration as well as physical rehabilitation. Though they were set up in 1988 solely in order to give new limbs to the war wounded, in 1994 the centres opened their doors to anyone who had a motor disability, whatever the cause. So far, they have produced 40,000 upper and lower limbs and 30,000 orthoses, including braces, corsets and orthopaedic shoes - and that's not counting the crutches and wheelchairs. Or 350,000 physiotherapy sessions.

But it’s not enough: disabled people need a lot more than a plastic leg, or to learn to walk. They have to get back into society, find a role, find dignity. In Afghanistan, where life is hard for everyone, they need help even more than everyone else. What kind of help? Schooling, and work, to give them a job. Or a loan to start up a small business. Difficult - but possible.

 In the Kingdom of the Blind the One-Armed Man is King  

When I’m in the Khair Khana quarter I often visit the shop belonging to three cousins called Akbar, Mafus and Rasul. In actual fact this is a barrow, selling cigarettes, matches, biscuits, sweets and nasuar , the cheap green muck so many people stick under their tongues to dull their senses a bit. Everything, including the barrow, was bought with a micro-loan. They make a strange group: Akbar, blind from birth, is the brain, Rasul and Mafus, amputees, are the arms. Arms that have to be watched, as they’re not very wide-awake types. But they all need one another, and complement one other, and the system works. Today they complain that business is bad. Maybe it’s true. But you can see that they’re happy. And when I think of what it took to persuade them to accept the loan...

A little over a year ago they came to ask for a gift of money, for charity. “Why don’t the three of you think up some small business for yourselves instead, that you could set up with a loan of 100 dollars maximum, at zero interest, repayable in 18 monthly instalments? You could choose whatever kind of work you liked.” For Rasul and Mafus this is a foreign language. Akbar, the blind lad, cottons on immediately: “I’ve nothing to give as a guarantee.” “Not necessary - your word will do.” “But what if I lose everything?” “Why should you? We’ll advise you and we’ll help you not to make mistakes. Hundreds of people like you have already managed it.”

A week later he submits his project with a list of the merchandise that needs to be bought. He’s chosen a corner at a crossroads, a good spot, lots of people passing by, he can tell by the noise. But he’s afraid, and decides to start off with just 40 dollars. We go to his home to talk to him: we want his whole family to know about the loan. It’s best to involve everyone. His mother’s a laundress, and a beggar when she has to be, 40 years old maybe, and looking 60. Three or four young siblings, father dead for years. Their home is one room, appalling. Still, take heart: 40 dollars, roughly two to be refunded every month, the rest is all for you and Rasul and Mafus. Who still don’t really understand much.

ICRC/S. Conlan ref. AF-E-00049
Gulbahar, ICRC limb-fitting centre, Jan 2002: A. Cairo adjusts a prosthesis 


The first few days are hard: Akbar can’t stay there on his own, Rasul has to keep an eye out to make sure that the passers-by don’t steal and that Mafus doesn’t eat the lot. Akbar pricks up his ears to hear if someone’s coming. He tells Mafus to keep on talking to make sure his mouth isn’t full. They do sell, but they make a lot of losses. Making an exception to the rule that says no second loans until the first one has been fully repaid, we add another 30 dollars. A miracle: sales take off, Mafus and Rasul learn a little, the repayments are made promptly. We continue to supervise them with weekly visits. Quarrelsome but united, they’re like three guards, a little lost-looking, standing over their treasure: the pride of being in business. And today, businessmen all, they tell me about their plan to buy four sheep with their next loan. Steady on there - first finish paying back this one. But who am I to rein in their galloping dreams?

 Learning Process  

For every child in every country, education is the future. Every time parents bring us their disabled children, we ask “Is your child going to school? Have you thought about what he or she will do when you’re old?” They generally reply that school is too far away and that books and copybooks are dear. Which is true. And if they have to choose, it’s the healthy children they choose to send to school. “But look, it’s the disabled one who’s going to need it most.” Some jobs will be unavailable to them. Heavy labour will be out. And Afghanistan is a place where work is hard and exhausting. Besides their muscles, above all disabled children need to develop their brains.

All the medical staff in the orthopaedic centre are actively involved in the programme. As they themselves are amputees, or paraplegics, or have suffered from polio, they know from their own experience how useful it is. And it’s during treatment that we get a chance to get to know the patients and their families. We discuss, suggest, advise. Many parents agree enthusiastically. “If you sign him on in the public school we’ll give him books and copybooks for the whole year. Every four months he’ll do a small exam to see whether he’s learning. But we’ll check with the teacher that he goes to school every day.” And that his schoolmates don’t leave him out of things. So far, almost 400 little boys have received help. Not many little girls, partly because it’s forbidden under the Taliban. But by dint of a thousand subterfuges, and being very discreet, we manage to help them too. Now some even speak English and know how to use a computer.

 A School of Dreams  

For many disabled children, though, school is inaccessible. Like Rauf, aged 10, paraplegic. The streets are one long hole, steps are steep, doors are narrow. Not a single toilet. He has good arms, but is useless from the waist down. An accident four months ago. They tried a pointless operation. We had tried to advise against it. And it cost them so much. With the leg braces he can stand up, but only if he leans against something. He always looks worried. Today he’s with his father, who it was hard to tell that there was no cure. Rather like killing him. In a few days Rauf will be let out. He will stay confined to the house, or the balcony, if he has one. With nothing to look forward to.

That’s what the education programme is for. And this is where Kabir comes in - a physiotherapist, our principal. “Would you like to study?” “Yes”, looking wide-eyed at the father who says, with pride and regret, “He used to be first in the class.” “Can you read and write?” “I used to be in fourth class.” And he adds sadly: “All the classrooms are on the first floor”. “A teacher will come to you, to your home.” “Just for me?” He can hardly believe it, used as he is to classes with up to 70 pupils. " Today we'll do the exam to see what class we should put you in. " Comical and endearing: Kabir, who is stout, wavering on the crutches, Rauf, tiny, swallowed up by the wheelchair. They talk. Rauf laughs. The exam shows he'd be best off starting again from third class. He'll begin on Saturday - that will give Kabir time to talk to the teacher. Who will be Munir, another person with a disability. And unemployed. Two birds with one stone: Rauf, paraplegic, will learn and will prepare himself for a slightly better future. Munir, amputee-cum-teacher, will have a wage. When Rauf leaves the centre with his father he has a treasure with him: his school bag, complete with books, copybooks, ball-point pens and coloured pencils. He clasps it tightly. At home he'll show it proudly to everyone, waiting impatiently for Saturday when he can say " Salaam  mahalem " - " Good morning, teacher " . And start putting the pieces back together to build his precarious future.


For Kabir, the principal, it was also hard to start living again after losing a leg. Being disabled gives him the motivation that makes him the driving force behind the education programme. He used to be a university lecturer and a member of the Afghan Academy of Sciences. He lived and studied abroad for a number of years. Then he came home. In 1994 his house was hit by a missile. Luckily, he was alone - his wife and two children were in the village. No one knows how he managed to get down six flights of stairs on his own. His leg was in bits. At the hospital he refused to be amputated and begged them to let him die - or to help him die. Instead, the surgeon authorized the amputation, forging his signature, and against his will he survived.

ICRC/S. Conlan ref. AF-E-00050
Gulbahar, ICRC limb-fitting centre. Next step, Jan. 2002 


In Kabul it was civil war, with bombs and more bombs falling all over the place. And still more bombs. And not a trace of a journalist to be seen - everyone had forgotten all about Afghanis tan. Red Cross ambulances rushed everywhere to replenish medical stocks in the hospitals. Which were bursting at the seams - two patients to a bed. Kabir left the hospital a broken man. He turned up at the orthopaedic hospital without conviction, simply because he had been told to come, that we would give him a leg. It was hard for us too. We had left the machinery for making the prostheses at the other side of the city, which was cut in two by the front line, which we had to cross every day. On one side the Tajiks, who were arresting the Hazara, and on the other side the reverse. We had friends and clients in both factions, so we were allowed to cross over. Kabir came with us, indifferent to everything. There was no doubt he was still hoping to die. " I don't want to see my family, and I don't want them to see me like this. " He says little. He’s polite, but he never smiles. He learns to walk with the prostheses.

We need a new physio, whom we'd train. I offer him the job. He's not interested. I push. I tell him we need him, that it's he who would be helping me. He agrees so as not to offend me. Shock therapy - we leave him no time for thinking, we keep him occupied. The whole time. One day he asks me about my country. He quotes Gramsci, he criticizes Stalin and Togliatti, about whom he clearly knows more than I do. See - we're getting there, we're getting there... We continue to keep him under pressure. He learns fast. He knows how to get patients to listen to him, how to be convincing and authoritative. And finally, one day, he talks about his home for the first time. He talks about repairing it. And calling his wife and children back. I can see that we're nearly there. One more little push - he used to be a teacher, a teacher he must become again. We have around 40 instructors. They’re willing, but a bit at sea. And I can't help them - it's not my culture, it's not my school. I need to be guided myself. I need a principal. He ac cepts. Now we really are there. Kabir has come to life again - committed, earnest, passionate. He loves teaching - you can see it, it's his life. He also quite likes showing off what he knows, which is a fair amount. As a physiotherapist, he works every day with the surgeon who forged his signature. I think he's grateful to him now.

 Kabul, November-December 2001 - January 2002