Problems in the rehabilitation of the physically disabled in rural areas of India
A. K. Agarwal *
M. K. Goel *
Some 550 disabled patients were examined by a rehabilitation team by organizing a rural camp at Meerut. This rehabilitation team consisted of orthopaedic surgeons, doctors, a pros-thetist, an orthotist, a medical social worker and other skilled workers, Out of the 550 disabled patients, 271, were amputees, and 184 cases had poliomyelitis. Males predominated by 4:1. Disability was most common up to the age of 30 years. Of the 271 amputees, 146 were of upper limb while 125 were of lower limb. Only 86 lower limb amputees were suitable for fitting a prosthesis, while 39 others needed surgery or physiotherapy. Only 87 of the 184 polio cases were found suitable for appliances, the remainder needing surgery or physiotherapy.
Ways of reducing the numbers of disabled were examined and improved rehabilitation procedures suggested.
It has been observed that although the percentage of disabled people in our district of India was quite high, their attendance at our city-based comprehensive rehabilitation centre was comparatively poor. The disabled residing in rural areas were not utilizing the services available due to various reasons such as ignorance of the available facilities, socio-economic causes, fears of surgery and city life, and lack of proper transportation facilities.
It was therefore thought that keeping our personnel in the bigger cities with adequate
rehabilitation services would not help the masses residing in rural areas. The ultimate goal of providing modern rehabilitation services to the disabled would not be complete unless we ourselves moved to help the rural population. With this in mind a camp was organized in the rural area of Meerut 60 km from New Delhi, the capital of India.
A rehabilitation team comprising two orthopaedic surgeons, three resident doctors, an orthotist, a prosthetist, a leather worker, a medical social worker and three artisans, attended the camp. The team was equipped to fit temporary artificial limbs and to measure the patients for prosthetic and orthotic appliances. The funds for the camp were provided by philanthropic persons. Before the camp was set up it was publicised, patients were registered, and they were given appointments for their clinical examination.
A pro forma was used for assessing the disability and all the patients were screened by the rehabilitation team. The measurements of patients who required artificial limbs and orthotic appliances were taken. A few of the patients wçre also provided with temporary artificial limbs for immediate walking.
The response of the rural population was very encouraging and a total of 550 patients attended the camp. It was found that 386 patients were below the age of thirty years and males outnumbered females by 4:1. In males the numbers of disabled were at a peak between 11 and 30 years of age, while in females the peak incidence was up to the age of ten years of age (Table 1 ).
It was found that 49.27 per cent of the disabled patients had amputations, 33.45 per cent had poliomyelitis, 8.18 per cent had cerebral palsy and hemiplegia, 1.09 per cent had degenerative conditions, 0.90 per cent had congenital anomalies, and 7.09 per cent had other causes (Table 2 ).
Of the 271 amputations 125 were of the lower limbs and 146 of the upper limbs. Of the 125 lower limb amputees, only 86 stumps were suitable for fitting with a prosthesis. Surgery or physiotherapy was needed by the remaining cases. In 54 cases, a temporary artificial limb was fitted immediately (Table 3 ).
Of the 184 patients with post-poliomyelitis disability, 87 were capable of being fitted with orthotic appliances, and the remainder were advised to have surgery or physiotherapy before being fitted with appliances (Table 4 ).
It was observed that the majority of disabilities were either amputations or due to poliomyelitis. Amputations of the upper limb were more frequent than those of the lower limb. This may be attributed to modern methods in agriculture and other agricultural-based cottage industries. In the lower limb, train and motor car accidents were the main factors leading to amputation. In the study, very few cases of amputation were due to tumour or vascular impairment.
In the present society in India females still remain confined to the home, while males are more exposed to the external environment which may be the reason for their greater incidence of disability. Many of the amputees were neglected for as long as thirty-five years and, in many of the cases, revision of the stump was also required as bony projections, flabby musculature, contractures and sinuses were common.
Close questioning by the medical social worker revealed many reasons for the patients not attending a city-based rehabilitation centre. Amongst them were lack of knowledge of the existence of a rehabilitation centre, socio-economic reasons, fear of city life, and lack of transport.
These observations have led us to believe that problems of the disabled residing in rural areas of our country are quite different from those of the urban areas. Some 80 per cent of our population reside in rural areas and serious thought must be given to their adequate rehabilitation.
Several improvements could be considered:
It can be made known through education and publicity that the disabled can be rehabilitated and can once more be independent and earning members of society.
There should be more emphasis on the prevention of disabilities. Oral vaccine campaigns could prevent poliomyelitis. Road safety campaigns could reduce car accidents and similar campaigns could be aimed at train accidents and cottage industry accidents.
Early management of the disabled should be encouraged as it would result in better rehabilitation as well as helping to prevent crippling complications.
It was also observed that the conventional type of artificial limb did not suit the amputees from the villages. They needed an artificial limb which would permit them to walk bare-footed, allow them to squat and which would also permit them to sit in a cross-legged position. In addition these limbs should be economic, strong, simple, and easily repaired.
Immediate fitting of temporary artificial limbs to these amputees in their villages, while they awaited their permanent artificial imb, would help tremendously in boosting their morale as well as resulting in early gait training and improvement in muscle power.
These improvements could be achieved by a three tier system of medical rehabilitation services:
At village level.
At city level.
At Medical College level.
In addition there should be some model comprehensive centres which would conduct teaching, training and research programmes.