Community based rehabilitation: a strategy for peace-building

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ralBMC International Health ssBioMed Centand Human RightsOpen AcceBMC International Health and Human Rights 2002, 2 xDebateCommunity based rehabilitation: a strategy for peace-buildingWilliam Boyce*1, Michael Koros2 and Jennifer Hodgson3Address: 1Community Health and Epidemiology and Education, Queen's University, Kingston Ontario Canada, K7L 3N6, 2Canadian International Development Agency, Central & Eastern European Branch, Hull Ouebec, Canada, K1A 0G4 and 3International Programs, Faculty of Arts & Science, Queen's University, Kingston Ontario Canada, K7L 3N6E-mail: William Boyce* -; Michael Koros -; Jennifer Hodgson -*Corresponding authorAbstractBackground: Certain features of peace-building distinguish it from peacekeeping, and make it anappropriate strategy in dealing with vertical conflict and low intensity conflict. However, sometheorists suggest that attempts, through peace-building, to impose liberal values upon non-democratic cultures are misguided and lack an ethical basis.Discussion: We have been investigating the peace-building properties of community basedapproaches to disability in a number of countries. This paper describes the practice and impact ofpeace-building through Community Based Rehabilitation (CBR) strategies in the context of armedconflict. The ethical basis for peace-building through practical community initiatives is explored. Anumber of benefits and challenges to using CBR strategies for peace-building purposes areidentified.Summary: During post-conflict reconstruction, disability is a powerful emotive lever that can beused to mobilize cooperation between factions. We suggest that civil society, in contrast to state-level intervention, has a valuable role in reducing the risks of conflict through community initiatives.BackgroundRole of Civil Society in Peace-buildingIn the 1992 report Agenda For Peace, the Secretary Gener-al of the United Nations defines peace-building as "actionto identify and support structures which will tend tostrengthen and solidify peace in order to avoid a relapseinto conflict" [1]. Because this definition is extremely gen-eral, it has provoked tremendous interest and considera-ble discussion. For example, the Canadian Department ofForeign Affairs now defines peace-building as "a set ofmeasures that create a sustainable infrastructure for hu-man security". Furthermore, Foreign Affairs notes thatgovernance, sustainable development, and social equity"are important elements of sustaining global peace [2].However, these general definitions of peace-building re-quire refinement, especially in relation to various forms ofconflict that are endemic in the early twenty-first century.In the search for a term describing conflict which encom-passes such diverse conditions as full-scale armed conflict,military occupation, and popular rebellion, it is helpful touse 'political violence', as described in the epidemiologi-cal work of Zwi and Ugalde [3][4]. These authors identifyfour major forms of political violence: structural, repres-Published: 4 November 2002BMC International Health and Human Rights 2002, 2:6Received: 19 April 2002Accepted: 4 November 2002This article is available from: 2002 Boyce et al; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL.Page 1 of 10(page number not for citation purposes)"the concept of human security recognizes that humanrights and fundamental freedoms, the rule of law, goodsive, reactive, and combative. These forms of conflict de-scribe situations of political violence varying fromBMC International Health and Human Rights 2002, 2 societal inequities in resources and power (struc-tural political violence), to the processes of militarizationand war (combative political violence). The frameworkalso includes informal forms of political violence by thestate such as political assassinations, torture, disappear-ances, detention, and harassment (repressive political vi-olence), as well as violence against the state in the form ofcoups d'etat, guerrilla warfare, and revolutionary force (re-active political violence).With respect to these various forms of conflict, R. J. Fisherdistinguishes peace-keeping from peace-building but doesso in relation to another typology of conflict, either hori-zontal or vertical [5]. Fisher defines peace-keeping as "adissociative approach in which a third party intervenessimply to keep the warring parties apart and maintain theabsence of direct violence. This approach is appropriate ina horizontal conflict such as combative or reactive politi-cal violence, between equals who are relatively weak (be-cause strong parties can be their own peace-keepers), butis not appropriate to vertical conflicts between un-equalsbecause it freezes the status quo in a biased manner [6].Thus, peace-keeping is not an appropriate strategy in ver-tical conflicts, structural or repressive political violencewhich "are highly resistant to de-escalation, in part be-cause of a host of social-psychological processes, includ-ing cognitive rigidities and distortions, self-fulfillingprophecies, and irrational commitment mecha-nisms....Due to the complexities of such conflicts ... [thereis] a set of interlocking ethnic, political, and economic fac-tors in which no one issue can be resolved by itself" [7].By far, the most common type of conflict in the world to-day is vertical in nature, involving 'low intensity conflict',which is "based in deep-seated racial, ethnic, and religioushatreds combined with structural cleavages and politicaloppression that result in the victimization of one or moregroups through a denial of their fundamental needs" [8].Fisher describes features of peace-building which distin-guish it from peace-keeping, and suggests the appropriate-ness of peace-building strategies in dealing with verticalconflict and with the very nature of low intensity conflict.He states that peace-building is "an associative approachthat attempts to create a structure of peace both withinand among nations a structure that removes the causesof war and provides alternatives to war. This structure in-volves relations among a large domain of several partiesthat are equitable, interdependent, include a variety ofpeople and types of exchange, and have a supportive su-perstructure.... Peace-building thus requires a process ofnonviolent social change toward equality" [9]. Therefore,in Fisher's view, peace-keeping keeps relatively balancedMulti-track diplomacy is a practice that includes peace-building and implies that, in addition to formal diplo-matic efforts to resolve conflict, other methods are of val-ue. The relevant external actors in peacekeeping activitiesare usually other national governments and multilateralagencies. External actors in peace-building efforts, on theother hand, may be from a broader base. The phrase'Track Two diplomacy' was coined in 1982 by Montville[10] to describe activities occurring outside formal state-to-state, or Track One relations. The main objectives ofTrack Two diplomacy efforts are:X to reduce or resolve conflict between groups or nationsby improving communication, understanding, and rela-tionships;X to decrease tension, anger, fear, or misunderstanding byhumanizing the 'face of the enemy' and giving people di-rect personal experience of one another; andX to affect the thinking and action of Track One diploma-cy by addressing root causes, feelings, and needs and byexploring diplomatic options without prejudice, therebylaying the groundwork for more formal negotiations, orfor re-framing policies.Indeed, the basic premise of Track Two diplomacy "is thatthe expertise for dealing successfully with conflict doesnot reside solely within government personnel or proce-dures" [11].The importance of multi-track efforts to the success of for-mal peace agreements has been recognized by scholarssuch as Crocker & Hampson [12] whose study of fivepeace settlements (Cyprus, Namibia, Angola, El Salvador,and Cambodia), led to the distillation of several opera-tional and strategic rules of the road, one of which is ofparticular relevance here. They assert that civil society is akey player in peace-building:"Economic and social reconstruction is crucial to the suc-cess of the peace process. In addition to advancing humanrights, third parties have a crucial role to play in rebuild-ing and reconstructing civil society for long-term peaceand stability. There is a vital link between sturdy civic in-stitutions, including the norms and networks of civic en-gagement, and the performance of representativegovernment. Not only is civil society important to democ-racy, but it also has a significant role to play in consolidat-ing the peace process in countries making the transitionfrom war to peace. Because third parties often provide thenecessary foundations for democratic institutions, inter-national development agencies and non-governmentalPage 2 of 10(page number not for citation purposes)parties apart, while peace-building brings unbalancedparties together.organizations have a pivotal contribution to make to thetask of post-conflict rebuilding" [13].BMC International Health and Human Rights 2002, 2 and Halevy [14] have suggested several peace-build-ing activities that can be undertaken in support of a peaceagreement:X provide a sufficient level of internal security to enableeconomic activity to recover, to encourage refugees andinternally displaced persons to re-establish themselves,and to persuade the business community to invest;X strengthen the government's capacity to carry out key ac-tivities;X assist the return of refugees and internally displaced per-sons;X support the rejuvenation of household economies, es-pecially by strengthening the smallholder agricultural sec-tor;X assist the recovery of communities, in part throughprojects that address social and economic infrastructure;X rehabilitate physical infrastructure of crucial importancefor economic revival, such as roads, and communicationsystems;X remove land mines from major transport arteries, fieldsand other critical sites;X stabilize the national currency and rehabilitate financialinstitutions; andX promote national reconciliation.Of course, these activities are part of traditional recon-struction efforts in many post-conflict countries. Howev-er, to achieve peace-building dividends, certain dynamicsmust be understood which can be illustrated by examin-ing this strategy through an ethical perspective.DiscussionThe Ethics of Peace-buildingThere are a number of social relationships involved in theprocess of peace-building. The obvious relationship,which is the primary focus of peace-building, is the onebetween the opposing groups during periods of conflict.However, the peace-building process introduces a new setof relationships between the specific groups recoveringfrom conflict situations, and the external observers of theconflict who participate in the peace-building process. It iscommonly assumed that peace-building reflects humani-tarian, honourable intentions in seeking to stop the vio-lence and human rights abuses that occur during conflicts.unforeseen, negative consequences. Two types of negativeconsequences from the efforts of peacemakers, -keepers,and -builders, as well as international development assist-ance agencies and their staff, have been identified in re-cent years through the development of peace and conflictimpact assessment (PCIA) approaches. One set of nega-tive consequences arises from the actions and approachesof individuals and organizations. The other set arises fromthe political instrumentalization of external resources andinterventions by domestic political actors intent on re-solving conflict through violence. The work of Mary An-derson and the Collaborative for Development ActionInc., has examined the former in considerable detail andat a micro-level in the "Local Capacities for Peace" project.Donor approaches to assessing the latter have been sum-marized in "Conflict Impact Assessment of EU Develop-ment Cooperation with ACP Countries: A Review ofLiterature and Practice", by Manuela Leonhardt. [15].These potentially negative consequences provide the ra-tionale for examining the ethics of peace-building inter-ventions.Canada's foreign policy objectives include the projectionof Canadian values and culture. These values, which canbe generally characterized as liberalistic, have also led Ca-nadians to embrace multicultural ideals. The 1996 recom-mendations on Canadian Foreign Policy andInternational Peace-Building include a directive that:The Canadian government should ensure that any peacekeep-ing/peace building interventions are based on promoting, pro-tecting and reflecting Canadian values, including humanrights, rule of law, and multicultural tolerance [16]. (em-phasis ours)Although this directive is intended to stress the impor-tance of promoting respect for human rights and toler-ance of multiculturalism in other societies, it also impliesthat Canadians highly value cultural integrity when en-gaging in international relationships.Canada is not alone in this view. Liberal values that un-derpin human rights are reflected in international law,and have been espoused by a large number of countries,representing a large sector of the human population. Al-though liberal values may be largely Western in origin,they are assumed to rest on a fundamental respect for in-dividual persons, a respect which is not only prevalentwithin a diversity of cultures, but also requires attention tomulticultural rights. Thus, widespread acceptance of hu-man rights policies should serve to discourage violentconflict and should provide a stable foundation for lastingpeace. From an ethical perspective, it therefore becomesPage 3 of 10(page number not for citation purposes)But given the compromised state of post-conflict groups,there is significant risk that external intervention can haveacceptable and beneficial to introduce and promote liber-al values within post-conflict societies. Indeed, the 1996BMC International Health and Human Rights 2002, 2'Policy Options for Post-Conflict Reconstruction' suggestthat:the democratic ideals of respect for human rights and free elec-tions should be conceived of as a core component of Canadianreconstruction efforts and promoted regardless of a lack of localdemocratic traditions [17].However, some liberal theorists suggest that attempts toimpose liberal values upon non-democratic cultures aremisguided. In cases where such cultures oppress theirmembers,the initial moral judgment is clear enough. From a liberal pointof view, someone's rights are being unjustly denied by their owngovernment. But what is not clear is the proper remedy, that is,what third party (if any) has the authority to intervene in orderto force the government to respect those rights? [18]International mechanisms for protecting human rights arenot always acted upon (e.g., Srebrenica or Rwanda), andprovide the basis for intervention to end those forms ofconflict which rely upon human rights abuses. But thisdoes not justify the imposition of liberal values on non-democratic cultures which refrain from blatant abuses. Ifthe imposition of liberal values on stable, non-democraticcultures is unjustifiable, then the imposition of such val-ues upon compromised groups involved in low intensityconflict may be viewed as equally unacceptable, as fol-lows.Low intensity conflicts not only destroy property and so-cieties, but also result in immense human costs. Peopleare wounded, disabled, or killed in violent conflict.Among the survivors, the psychological costs are immeas-urable. The loss of loved ones, home, security, and a nor-mal context for everyday living disables individuals,inhibiting their ability to interact with others. The strate-gic infliction of terror upon innocents further deprivesthem of their humanity. Rape, torture, and particularly thetargeting of children, all serve to strip individuals of theirconfidence and their sense of self. The impact of low in-tensity conflict is long-term. Once an individual's own se-cure identity has been displaced, the process ofrediscovering the self is necessarily long and difficult.However, despite the degradation of human beings thatoccurs during low intensity conflict, these occurrencescannot be viewed as tragedies that fully obliterate socie-ties. Many authors have criticised the fatalist 'apocalypticview' of conflict, which mistakenly assumes that post-con-flict development means rebuilding a society from noth-ing:This approach has been criticised by those who maintain thatarmed violence is in practice continuous with normal social ex-perience, suggesting that conflict does not necessarily corre-spond with social breakdown ... many communities areextremely practised at coping with adversity.... A lack of curios-ity about sociological and cultural causality invites operationalresponses which are insensitive to local social and cultural con-ditions. Indeed, to intervene in an emergency by ignoring indig-enous coping strategies is to increase civilian jeopardy. A primeaim of humanitarian operations should be to identify patternsof social resilience and vulnerability and reinforce local capaci-ties rather than introduce foreign perceptions and foreign re-sponses [19].Respect for social and cultural integrity, then, is of the ut-most importance in dealing with low intensity conflict sit-uations, when cultural identity is perhaps all that is left topersons who are compromised by violent conflict.Furthermore, Kymlicka suggests that the coercive imposi-tion of alien liberal values is likely to fail: "Attempts to im-pose liberal principles by force are often perceived ... as a formof aggression or paternalistic colonialism" [20]. When at-tempts at liberalisation are perceived this way, membersof non-democratic cultures are more likely to reject suchvalues. Kymlicka suggests that liberal values can only takehold in a society when those values are internally em-braced by members of that society. The key to the promo-tion of lasting values is to introduce those ideas graduallyand to support internally-driven movements for liberali-sation: "Since the most enduring forms of liberalization arethose that result from internal reform, the primary focus for lib-erals outside the group should be to provide this sort of support"[21].Thus, although Canadian foreign policy objectives in-clude the projection of Canadian liberal values, thesemust be promoted with caution in post-conflict situa-tions. The imposition of alien values upon individualsstruggling to regain their own identity, independence, andconfidence may cause unintended harm by inhibiting au-thentic cultural identities. Peace-building strategiesshould provide compromised individuals and groupswith an opportunity to rediscover their identities and sit-uate themselves in a context of peace. The opportunity forrediscovery of self is essential if any peace is to be lasting.Individuals who are compromised and threatened cannotenter into the process of building healthy, trusting rela-tionships that are necessary for a society to engage in sus-tainable, peaceful relations.Given these reflections on the morality of promoting Ca-nadian liberal values abroad, it is not surprising that thePage 4 of 10(page number not for citation purposes)1996 Canadian Foreign Policy and International PeaceBMC International Health and Human Rights 2002, 2 consultations yielded the following recommen-dation:Democratization should be the primary goal of Canadianpeace-building initiatives. At the centre of this lies the impor-tance of the reconstruction of civil society as a means of foster-ing indigenous democratic elements. Strengthening the social/economic sphere can create a political space for civil society todevelop, and can help democratic development that reflects lo-cal values and history [22] (emphasis ours).This recommendation recognises the need to respect thecultural integrity of post-conflict groups, while at the sametime supporting internal liberalisation. The question,then, is how to promote liberal values in post-conflict sit-uations, without taking advantage of the compromisedposition of those individuals and groups who are trying torebuild their lives.The successful promotion of such values requires an ap-proach which is both respectful of other cultures, andwhich allows others to appreciate the benefits of incorpo-rating liberal practices within their society. J.P. Lederach[23] suggests that a dialectical approach to the practice ofmediation, which he terms an 'elicitive model', may beuseful. Rather than imposing alien standards in resolvingconflict, the elicitive model seeks to discover and solidifythe resources that exist in a specific post-conflict context.There are several reasons to recommend this elicitivemodel as a peace-building approach. By empowering in-dividuals to speak for their own cultural traditions, it al-lows a voice to under-represented or oppressed groups.And in seeking resources within the specific contexts inwhich it is applied, it also demonstrates respect for the val-ue and integrity of the culture.However, mediation alone is not sufficient to achieve sus-tainable peace. The elicitive model of mediation necessar-ily focuses on past conflict and recalls the essentialdifferences that initially triggered unrest. Peace-buildingstrategies should also incorporate approaches that are for-ward thinking, and that demonstrate the common valuesshared by those affected by conflict. Some key perspec-tives must be shared by both sides, yet each group needsto comprehend the unique perspectives of the other intheir own cultural context. This expansion of self is whatphilosopher and political theorist Charles Taylor refers toas a 'fusion of horizons':we learn to move in a broader horizon, within which what wehave formerly taken for granted as the background to valuationcan be situated as one possibility alongside the different back-ground of the formerly unfamiliar culture. The 'fusion of hori-comparison, by means of which we can articulate these con-trasts [24].It is only through such a fusion that we can truly begin toappreciate the value of other perspectives. The ideal peace-building approach will enable this fusion of horizons tooccur between opposed groups, as well as between the vic-tims of conflict and peace-builders.There are a number of frameworks, methods, tools andprocesses being used by a variety of development actors toachieve and monitor such peace-building strategies[25,26]. These tools are used at the formulation, monitor-ing and evaluation stages in the programme cycle of hu-manitarian, reconstruction, and traditional developmentinterventions [15]. Following upon the path-breakingwork of Kenneth Bush [27] in this area, donors and otherdevelopment actors recognize that their interventions arenot conflict neutral and are seeking ways of increasing theconflict-sensitivity of their activities in operationally feasi-ble ways.Community Based Rehabilitation Approaches to Peace-buildingWe now turn to an examination of the particular strategiesand benefits that community based approaches to peace-building can entail. Perhaps the most common human se-curity concern during conflict is that of basic health, uponwhich life depends. Many practical examples of peace-building can be found in the health sector [28]. 'Days ofTranquility' and 'Corridors of Peace' agreements havebeen negotiated by UNICEF (United Nations Children'sFund) and other agencies, including the InternationalCommittee of the Red Cross, the World Health Organiza-tion, and various ministries of health, churches and non-governmental organizations. These agreements are de-signed to allow activities such as immunization programsand the distribution of relief supplies during special cease-fires, demonstrating the common concern of belligerentsfor the health of children. Strategies that channel such as-sistance through community based health organizationshave been used in Afghanistan, El Salvador, Lebanon, Su-dan and Iraq. Interestingly, the focus of many efforts hasbeen on prevention of childhood disability caused by po-lio. Disability is a powerful emotive lever that can be usedto mobilize cooperation between factions. Consequently,we have been investigating the peace-building propertiesof community based approaches to disability in a numberof countries.We use the general term disablement to include impair-ment, disability, and handicap, which vary during differ-ent stages of conflict - from instability to conflict toPage 5 of 10(page number not for citation purposes)zons' operates through our developing new vocabularies of reconstruction. For example, impairments incurred dur-ing overt conflict may include peripheral nerve injuriesBMC International Health and Human Rights 2002, 2 by bullet or shrapnel wounds; hand, foot, facial in-juries, or blindness caused by explosions or torture; andhead, chest, and orthopaedic injuries caused by collapseof buildings. After hostilities cease, civilians may contin-ue to suffer impairments, such as amputations and blind-ness due to land mines. These impairment problemsresult in needs for specific clinical programs such as sur-gery and prosthetics.Disabilities, or functional problems, which can occur dur-ing overt conflict may include being weak, unable to see,and unable to protect oneself during armed attack. At lat-er post-conflict stages, being unable to rapidly respond tocurfew, and being unable to look after basic hygiene andself-care may become problems. These functional prob-lems result in needs for specific rehabilitation programssuch as muscle strengthening, mobility training, vocation-al retraining, and provision of adaptive devices.Handicaps, or social responses to disablement, that are ex-perienced by persons with disabilities during times of ac-tive conflict often include being unable to safely earn aliving. In post-conflict situations, one may also be stigma-tized as a disabled veteran. These social problems resultin needs for specific community based programs such aspublic education, income generation projects, accessibili-ty modifications, and peer support programs.Community Based Rehabilitation (CBR) is a response, inboth developed and developing countries, to the need foradequate and appropriate rehabilitation services to beavailable to a greater proportion of the population withdisabilities. The World Health Organization Expert Com-mittee on Rehabilitation has defined CBR as an approachthat involves, utilizes, and builds on existing resources indisabled persons themselves, their families, and commu-nities [29].CBR can be contrasted with institutionally-based and out-reach rehabilitation services. In CBR, there is a large-scaletransfer of knowledge about disabilities and rehabilita-tion skills to people with disabilities, their families, andmembers of the community, such that resources becomeavailable at the community level and rehabilitation is 'de-mocratized' [30]. Such democratization and access to theresource provided by technical rehabilitation knowledgeand skills are important principles, with obvious links tothe peace-building process.On a practical level, CBR programs aim to rehabilitate andtrain individuals with disabilities, as well as to find waysto integrate them into their communities. In effective CBRprograms, persons with disabilities, their families, theservices for persons with disabilities are seriously limitedor totally absent. The essential feature of CBR is its focuson the processes supporting partnership of diverse groupsand community participation. CBR programs assist localpeople to develop sustainable processes and systems that:deliver clinical services in remote areas; train personnel;promote Disabled Peoples' Organizations; plan, manageand coordinate local services; and provide appropriatetechnology. In areas of armed conflict, CBR programs typ-ically aim to work with other agencies that are active inemergency aid and re-construction, which are often theonly functioning organizations in the area.Introducing rehabilitation services at a local or communi-ty level removes many obstacles to care that are associatedwith traditional institutional care. The difficulty of travelfor persons with disabilities, and its expense, are eliminat-ed or reduced to a minimum. The individual is not isolat-ed from the community. Family members andcommunity volunteers are part of the rehabilitative proc-ess. Community members can see what the person with adisability is achieving. This transparency to rehabilitationcan help integrate the person into the community, a com-munity that can then value the unique contribution thatthe person is able to make.It has often been stated that there is no blueprint for a CBRproject [31]. Approaches to the implementation of CBRare context-specific, and are determined by the diversity ofsocial and demographic factors that are present in thecommunity [32]. This is because countries, regions, andcommunities vary enormously with respect to their ad-ministrative structures, economic and cultural conditions,population distribution, and financial and workforce re-sources. Each of these factors must direct the nature of theapproach to rehabilitation, if the program is to be indeed'community-based'. Nonetheless, drawing upon anemerging consensus in this field, a useful framework hasbeen formed of what can be considered 'key elements' ofCBR [33].In many countries, circumstances of conflict complicatethe development of these key elements [3537]. Experi-ence in a number of situations of armed conflict (CentralAmerica, Bosnia, Afghanistan, Sri Lanka) suggests thatCBR has a constructive role to play in peace-building. As apreventive and post-conflict peace-building strategy, CBRoperates in several of the areas mentioned by Ball and Ha-levy as important for civil society initiatives and it canmake important contributions to economic and social re-construction [38]. However, adapting CBR programs sothat these contribute to the process of peace-building, anddo not have unintended negative consequences, is crucialPage 6 of 10(page number not for citation purposes)community, and health professionals collaborate to pro-vide non-institutional services in an environment where[39]. The following describes some common ways ofBMC International Health and Human Rights 2002, 2 the key elements of CBR programs to increasetheir peace-building impact.The 'Promotion of Positive Community Attitudes andBehaviours towards Disability' usually involves de-stig-matizing persons with disabilities, often through promot-ing positive role models. CBR approaches have facilitatedthe integration into schools of disabled refugee childrenand supported alternatives to institutions for disabled,displaced, and orphaned children in Sri Lanka. In Pales-tine, program personnel from a variety of health and so-cial development agencies have been encouraged to avoidpreferential treatment of persons injured in the Intifada.This strategy has helped to reduce inequities between in-jured combatants and civilians and has led to gains for allpersons with disabilities that previously had been difficultto achieve. Legislative and bureaucratic measures that in-clude persons with disabilities in public services have alsobecome symbols of equality in Palestine [40,41].The 'Empowerment of Persons with Disabilities ena-bling Integration within Society' can be achieved directlyby disabled persons' organizations, but preferably bythose with experience in politically dynamic situations. InCambodia, Afghanistan, Mozambique, and Lebanon,members of Disabled Peoples' International consult tonational disability organizations to improve their abilitiesto develop self-help programs and also conduct advocacywith their governments to improve local rehabilitation ef-forts. Fora have been organized in these post-conflict soci-eties for persons with disabilities and the public to discussthe needs of disabled persons. Organizations from differ-ent political factions in Afghanistan and El Salvador havebeen linked by disability organizations in common caus-es, such as International Disability Day on December 3. Incontrast to the Palestinian example above that had to con-tend with traditionally negative attitudes towards disabil-ity, this strategy has utilized conflict-injured persons'status and visibility as victims of war to achieve benefitsfor all other disabled persons.'Knowledge and Skills Transfer to Promote Self-helpSkills' is a fundamental principle of CBR. Standard CBRtraining focuses on problems such as child developmentaldisabilities, polio, blindness, and stroke. CBR trainingmodules for low intensity conflict areas must instead fo-cus on major traumatic musculo-skeletal impairmentsfrom head injuries, multiple fractures, peripheral nerve in-juries caused by projectiles, traumatic amputations fromlandmines, and torture injuries. In Sri Lanka, joint train-ing in CBR skills for both Sinhalese military and Tamilcommunity groups exposed these different factions tocommonalities of the disability experience and promotedopportunity and must be acted upon quickly before sepa-rate rehabilitation services are established for differentgroups, which then become difficult to reconcile.'Development of Rehabilitation Services/ResourcesBased upon Needs Identified by Persons with Disabili-ties and their Families' often involves conducting a disa-bility prevalence survey and detailed needs assessment.However, CBR programs in conflict areas must prioritizeaction over lengthy planning processes if they are to havea peace-building impact. Rapid community-based assess-ment and evaluation methods for physical disability andpsychosocial trauma have been developed to assess needsas well as local response capacities [42]. Such rapid disa-bility assessment teams are necessary for respondingquickly in emerging war zones such as Central Africa, aswell as in large-scale disasters such as earthquakes.'Community Decision-making, Implementation, andAccountability to the Community' are routine in CBR.However, in post-conflict societies, communities are oftendivided. In Sri Lanka, community reconstruction in con-flict areas has addressed disability access problems, buthas also occasionally required relocation of valued publicservices such as transportation and recreation facilities.Such relocation has to be done with particular sensitivityor there is a risk of increasing tensions within communi-ties that are still suspicious of each other [43].'Partnership and Cooperation among Persons with Dis-abilities, their Families, the Community, and Rehabili-tation Personnel' is a core practice in CBR and involvestraining local rehabilitation workers (using a 'Training ofTrainers' model), developing appropriate technology, andbuilding peer support networks. This type of cooperationhas been extended to include national groups that werepreviously in conflict. For example, in southern Africa in-ter-country disability programmes have brought togetherformer political adversaries for policy, sports, and culturalexchanges and have demonstrated possibilities for recon-ciliation [44].'Development of Rehabilitation Technology UtilizingLocal Skills and Materials' ensures long term CBR sus-tainability. In areas of low intensity conflict, local techni-cal support persons (e.g., carpenters, welders) can besought out for assistance prior to training new techniciansor developing new orthopaedic workshops that may ex-clude local capacities. This approach has been used to re-inforce support for local community economicdevelopment by disability organizations in Angola. Emi-grants from countries in conflict can also be mobilized intheir new homes to donate rehabilitation equipment,Page 7 of 10(page number not for citation purposes)mutual assistance between the groups. Such cooperativetraining can be only achieved during specific windows ofprosthetics, and orthotic supplies.BMC International Health and Human Rights 2002, 2'Co-ordination with, and Referral to, a Network of Spe-cialized Interventions, Including Institutions, to Pro-vide Professional and Technical Support and Trainingwhich may be Unavailable within the Community' en-sures that disabled persons in the community are support-ed by other technical agencies. In areas of conflict,national development programs (for example, primaryhealth care, food and agriculture, rural and urban re-con-struction) can be integrated with CBR programs so thatthe needs of persons with disabilities, including ex-com-batants, are considered and there is less chance of exclu-sion. In Afghanistan, disabled persons' organizations havebeen linked to such national reconstruction planning[45]. Finally, organizing national and regional conferenc-es for CBR information dissemination, networking, andstrategic planning can demonstrate the benefits of a multi-sectoral approach to national planners as they gain insightinto the complex interaction between disability, educa-tion, and employment.Those who choose to wage war have only one remainingrelation of interdependence, and that is the objective ofmutual destruction in a sense, the very negation of thatremaining relation. To achieve peace, this one negative re-lation of interdependence must be transformed into sev-eral positive relations of interdependence on the cultural,economic, social and productive planes. While a focusonly on CBR for developing such relations of interdepend-ence is clearly insufficient, it is a remarkably useful start-ing point.CBR, because of its focus on supportive community proc-esses, on the value of diversity, and on universal access tothe means needed to lead a fulfilling life, is a very positivemeans of re-founding relations of interdependence on abasis that can promote peaceful conflict mediation andresolution. Where disability is the consequence of violentarmed conflict, CBR strategies that highlight persons withdisabilities provide the traumatized society with an op-portunity to perceive the actual human result of the con-flict. A tangible and direct consequence of doing this is tocreate the means whereby those who were engaged in, oraffected by, violent conflict as combatants or as civilianscome to grips with the need to (re-)integrate persons withdisabilities as part of the psychological healing of the pop-ulation at large. Rather than focusing on divisive issues,CBR is a positive, forward-thinking approach that maycontribute to peace-building.In terms of foreign policy agendas of donor countries, aCBR focus on integration of persons with disabilities pro-motes liberal values and human rights. Since low intensityconflicts cause disability in individuals, and in seeking toconflict is clear. Rather than imposing liberal values in avacuum, CBR introduces them by example in a clear, ac-cessible, and tangible manner. Persons from non-demo-cratic cultures are more likely to internalize liberal valueswhen they are embodied in social phenomena and proc-esses to which they are exposed every day [46].While CBR focuses on the needs of individual personswith disabilities, it also recognises the need for integrationwithin a broad, stable social context. This social contextcasts a wide net: persons with disabilities live in familyand neighbourhood contexts, work in professional con-texts, and belong to religious or spiritual groups. In pro-viding greater visibility of persons with disabilities, CBRtouches people in all of these contexts and promotes lib-eral values in a non-invasive manner. Although CBR ap-pears to have a limited focus, its arena for the promotionof liberal values is great because it highlights what can bedone by those who have suffered the greatest losses.CBR promotes liberal values and contributes to peace-building because it works toward the 'fusion of horizons'prescribed by Taylor [47]. In identifying and making useof local resources and capacities, CBR enters post-conflictsituations with an implicit assumption of the value andabilities of other cultures, and a fundamental respect forpersons and their cultural integrity. In working to estab-lish self-sufficient programmes, CBR brings expertise andhumanitarian values to a context where they are wantedand welcomed. It can lend confidence to groups whoseself-assurance and identity have been critically compro-mised during periods of violent conflict. In building effec-tive local programmes, CBR efforts must engage in theinter-cultural dialogue that leads to Taylor's fusion of ho-rizons. Thus, CBR offers the additional benefits of estab-lishing open and trusting dialogue that can aid inresolving conflicts and discourage future violence.SummaryIn summary, several key benefits result from the integra-tion of disability issues and CBR strategies into the peace-building process:1. The immediate impact of CBR intervention with a crit-ical vulnerable group, whose immediate human security isin jeopardy, is significant. This early humanitarian re-sponse demonstrates compassion and may be viewed asboth symbolic and tangible catharses to warring factions, todonor agencies, and to civilian victims of conflict. Localvisibility is achieved in the early stages of CBR interven-tion because local capacity and domestic resources must,by the very nature of the intervention, be employed to asignificant degree. Furthermore, CBR can alleviate povertyPage 8 of 10(page number not for citation purposes)move forward from periods of conflict, the need to redressthe harm done to individuals and families during thisin families in which a member is disabled, as well as min-imize the social costs that accrue to long term disability.BMC International Health and Human Rights 2002, 2 The process of implementing a CBR focus on disability,a strategy which by definition attempts to transcend gen-der, cultural, social class, religious, and political divisions,contributes to de-legitimizing politics and conflict whichdraw their legitimacy from the exclusion of human beingson the basis of these characteristics. CBR, addressing anemotive issue held in common, can diminish perceived bar-riers between disparate groups, thereby decreasing the legiti-macy of exclusionist political rhetoric.3. CBR, as one element of humanitarian intervention andmulti-track peace building, diplomacy and conflict resolu-tion, can provide examples of solutions to the problemswhich complex emergencies present in organizational andmanagement terms. CBR promotes a multi-sectoral ap-proach to problems that require interaction and negotiations.This interaction can alter the disposition of key managerswho control the health and social service infrastructure,by increasing their propensity to view local cooperativenon-hierarchical action as effective and worthwhile tosupport.4. Conflict can create opportunities to re-establish the phi-losophy and basis for social service and economic recon-struction. CBR, due to its focus on both personal changeand social adaptation through community based strate-gies, demonstrates opportunities for health, social, and eco-nomic reform in a non-contentious arena. This opportunitycan create community capacity and awareness of the or-ganizational forms and relationships required to addressthe interacting causes of poverty and disability. It can alsoheighten the expectation in local communities that theybe consulted in the design of longer term social recon-struction and development projects [48].CBR addresses an extreme form of vulnerability. If publicservices and support can reach the most vulnerable in so-ciety, especially in difficult circumstances such as low in-tensity conflict, then processes, systems and relationshipsare established whereby lesser forms of vulnerability andtheir social impacts may also be addressed. The impact ofCBR may be enhanced as a peace-building activity if itworks in a complementary manner with other communi-ty based initiatives. For example, community based deliv-ery of rehabilitation services in conflict zones can have amajor influence on the reconstruction and further devel-opment of the health care sector, and often with signifi-cant economic benefits through increased localemployment. CBR may also be a basis for extension ofcommunity based service delivery because of its multi-dis-ciplinary nature. More research is required about the ben-efits to peace-building associated with various types ofcommunity level public health and social developmentsuch as extension of credit and appropriate technology toexcluded groups. All these types of projects can have com-munity based approaches and this knowledge base needsto be tapped so that peace-building as a process, and as aCanadian foreign policy initiative, is robust and multi-sec-toral, drawing on the extensive experience of our develop-ment and humanitarian assistance agencies.To this end, it would be extremely helpful if peace andconflict impact assessments (PCIA) of CBR interventionscould be conducted as part of ongoing research and devel-opment of both CBR and PCIA. It is clear from early re-search on PCIA that, like CBR, it is context specific, andwhile some broad guidelines and indicators regardingconflict and peace impacts can be elaborated, tailoringthese to specific settings is essential [15]. Above, we havediscussed CBR and peace-building in general terms, andrelated specific CBR experiences familiar to the authors toethical thinking about liberalism and to current Canadianforeign policy. Further cumulative reflection on, and dis-tillation of, lessons learned from CBR interventions in re-lation to peace and conflict impacts is necessary. Thiscould provide the basis for eventually understanding therelative impacts on peace-building of CBR and other inter-ventions aimed at providing community based social sup-port services in a non-discriminatory manner in countriescharacterised by latent or overt low-intensity vertical con-flict, and accompanied by structural and repressive politi-cal violence.Competing interestsNone declared.Authors' ContributionsWB conceptualized the paper and drafted the manuscript,particularly regarding the application of CBR to peace-building. MK conceptualized the paper and drafted thesection on the role of civil society in peace-building. JHdrafted the section on ethics of peace-building. All au-thors read and approved the final manuscript.AcknowledgementsThe authors acknowledge the assistance of Emily Boyce and Diane Davies in the preparation of this manuscript.References1. Boutros-Ghali B: An Agenda for Peace. New York, United Nations19922. Department of Foreign Affairs and International Trade (DFAIT):Canada to Establish New Peacebuilding Fund. Press ReleaseOctober 30, 19963. Zwi A, Ugalde A: Towards an Epidemiology of Political Vio-lence in the Third World. Social Science and Medicine 1989,28(7):633-6424. Zwi A, Ugalde A: Political Violence in the Third World: A Pub-lic Health Issue. Health Policy and Planning 1991, 6(3):203-2175. Fisher RJ: The Potential for Peacebuilding: Forging a BridgePage 9 of 10(page number not for citation purposes)interventions. These interventions may include water,sanitation, agriculture, and income-generating projectsfrom Peacekeeping to Peacemaking. 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Boyce W, Ballantyne S: Community-based Rehabilitation in Ar-eas of Armed Conflict. 1997Pre-publication historyThe pre-publication history for this paper can be accessedhere: with BioMed Central and every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central yours you keep the copyrightPage 10 of 10(page number not for citation purposes)69Submit your manuscript here: based rehabilitation: a strategy for peace-buildingAbstractBackgroundDiscussionCompeting interestsAuthors' ContributionsAcknowledgementsReferencesPre-publication history


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