Physiotherapy, M ay 1986, voi 42 no 2 51 Is Rehabilitation o f the Rural D isabled a Realistic Objective? p a m M cLa r e n IN T R O D U C T IO N In co n si d e ri n g the feasibility o f r e h a b i li ta t io n o f the rural disabled there are initially three co n ce p t s which should be addre ss ed. These are re h a b i li ta t io n , dis ab le ­ ment, an d rural disability. R E H A B IL IT A T IO N ‘R e h a b i l i t a t i o n ’ is usually de fi ne d as the third ph a se in medicine ( p r e v e n ti o n being the first, an d cura tive care the second). T he 1969 W H O E x p e r t C o m m it te e on M ed ic al R e h a b i l i t a t i o n 1 d ef i n e d ‘r e h a b i l i t a t i o n ’ as follows: ‘the co mb in ed a n d c o o rd in at e d use o f medical, social, ed u ca t io n a l, an d v o c a ti o n a l m e as ure s fo r tr ai n i n g or re t ra i n in g th e in d i v id ua l to the highest possible level o f f u n c tio na l a bi li ty ’. E vidently, since 1969, the c o n c e p t o f re h a b i li ta t io n has b r o a d e n e d a n d the wor ld is n ow used to refer to a variety o f p r o g r a m m e s . Ho we ve r, a clos er look a t the above d e fi ni ti o n o f re h a b i li ta t io n sho w s t h a t the d ef in i­ tion relates m ai n ly to in t e rv e n t io n s aim ed at the indi vi­ du al an d neglects th os e aim ed at c h a n g in g the fa ct or s in his im m e d i a t e s u r r o u n d i n g s in th e soci ety as a whole.2 In 1981 a W H O e x p e r t C o m m i t t e e r e c o m m e n d e d the use o f the fol low ing de fi nit ion fo r reh ab il it at io n: “ R e h a b i l i t a t i o n i n c l u d e s all m e a s u r e s a i m e d a t red uci ng the im p a c t o f d is ab li n g a n d h a n d i c a p p i n g co n d it io n s , an d at e n a b li n g the disa ble d an d the h an d ic a p p e d to achieve social int eg ra tio n . R e h a b il it a ti o n aims n o t only at t r a in i n g dis abled an d h a n d ic a p p e d p er s o n s to a d a p t to th ei r e n v i r o n ­ me nt , b u t also at in t er v e n i n g in th e ir i m m e d i a te e n v i r o n m e n t an d soci ety as a w h o le, in o r d e r to facilitate their social in te g ra tio n. T h e disa ble d and ha n d ic a p p e d themselves, their families, and the c o m ­ m u ni ti es the y live in s h o u l d be involved in the p la n n i n g and i m p l e m e n t a t i o n o f services rela ted to r e h a b i li ta t io n . ’3 Pam McLaren, M.SC. (Occup. Ther.) O ccupational Therapist at Manquzi Hospital, Kwa Zulu and doctoral student of the D epartment of Community Health, University of the Witwatersrand, Joh ann es bur g Paper read at the Biennial Conference of the South African National Council for the Blind, Octob er 1985, Pretoria. Reprinted with permission from the official jo u r n al of SANCB — Infam a, February 1986 T h is d e fi n it io n in cl u de s the p re ve n ti ve a n d cu ra t iv e m e a s u re s w hic h were d eficient in th e 1969 defi nit ion a n d wh ich are i m p o r t a n t in r e d u c i n g the disability p ro b l e m . T h e e m er g en ce o f m ed ic al r e h a b i li ta t io n in the early p a r t o f the 19th ce n tu r y saw the d e v e l o p m e n t o f in s ti tu ­ t i o n - b a s e d r e h a b i l i t a t i o n (1BR) as the m o d u s o p e r a n d i . M o s t c o u n tr ie s o f th e w or ld hav e t o d a y at least one active re h a b i l i t a t i o n in s ti tu t io n . Th ese ins ti tut es have ach ie v ed m a n y ex c el le nt res ults an d have h a d a g r e a t influ en ce o n the a tt i t u d e t o w a r d s reh a b i li ta t io n . H o w ­ ever, th e im p a c t on th e d is ab il it y p r o b l e m as a whole has bee n small. S in c e 1969 t h e r e h as b e e n i n c r e a s i n g c r i ti c is m re g a r d in g the deficiencies in re h a b i li ta t io n services.4 A l t h o u g h the go a l o f p ro v i d i n g suf ficient r e h a b i l i t a ­ ti o n facilities f o r all t h o s e in need has b ee n ach ie ved in a few very dev el o pe d co u n tr ie s, it is ev id e nt t h a t it will n o t be achieved in the de v e lo p i n g c o u n t r i e s . 1 A n e x a m p l e o f w h y this will n o t be poss ibl e is given below: It was rece ntly r e c o m m e n d e d t h a t re h a b i li ta t io n services be set u p in th e c a p it a l city o f a c o u n t r y in Africa. F ig u re s o f m a n p o w e r need s (in 11 dif fer ent o c c u p a t i o n s ) a n d o f p a t i e n t t u r n o v e r were p ro v id ed . W h e n th e fi gu res were st u d ie d it w as f o u n d t h a t if the en ti re he a lt h b u d g e t fo r th e c o u n t r y were utilized solely f o r r e h a b i l i t a t i o n services, it w ou ld ta k e 60 y ear s to d e v e lo p th e nece ss ary m a n p o w e r and a b o u t 200 years to p ro v id e the pre se nt needy p o p u la t io n .w it h the desired a m o u n t o f care. T h e i m p r a c t i c a l i t y o f u s i n g I B R as t h e m o d u s o p e r a n d i in d e v e lo p i n g c o u n tr ie s is well illus tra te d by th is e x a m p l e . T h e d e f i c i e n c i e s in th e c o n v e n t i o n a l a p p r o a c h to r e h a b i li ta t io n ca n be lo o k ed a t in the areas of: a. p l a n n i n g deficiencies — p a r t l y d u e to lack o f a d e ­ q u a t e statistics o f the p r o b l e m , b. deficiencies in th e c o n t e n t o f services — p a rt ly d u e to e c o n o m i c co n st ra in t s, c. c o o r d i n a t i o n deficiencies — oft en cause d by p ro f e s­ si on al ‘t e r r o r i a l i s m ’. W H O c o n cl u de d t h a t ‘ow ing to the large g a p betw een ac tu a l needs an d th e p o t e n t i a l possibilities o f m e et in g th e m by utilizing p re s en t m e t h o d s o f pro v i d in g services, p re s e n t policies m u s t be c h a n g e d and a new set o f s o l u ti o n s m o r e in k e e pi n g with th e ac tu a l s i t u a t i o n a nd th e av a ila b le re so u rce s m u s t be creat ed and im p le ­ m en te d ’. 1 I will c o m e ba ck to this la te r on. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 52 Fisioterapie, M ei 1986, d e e l 42 no 2 D IS A B L E M E N T M u c h o f th e p r o b l e m o f i n a d e q u a t e st atistics with reg ar d to dis abilit y has been the lack o f un if o rm i ty in de fining the dif fer en t levels o f severity o f disability. W o o d st at e d t h a t ‘D is a b l e m e n t is a c o m p o u n d c o n ­ ce p t co n ce rn ed with the co n se q u en ce s o f disease and illness’.5 He we nt on to p o in t o u t t h a t th e medical model o f disease is co ncerned with the intrinsic situation, the o cc u rr e n c e o f s o m e th i n g a b n o r m a l w ith in the ind i­ vidual. T h is is followed by ex te r io r iz a ti o n o f the p r o b ­ lem, where so m e o n e becom es aw ar e o f th e a b n o r m a l o cc ure nce . In t u r n this ex pe ri e nc e if objectified as p e r f o r m a n c e o r b e h a v i o u r u n d e rg o e s al t er at io n , every ­ d a y activities m a y b e co m e restr ic ted , a n d the whole proces s ca n trigge r psycho lo gic al res ponses, which is referred to as illness b e h a v io u r . F inally, these o c c u r ­ rences are socialized as th e a w are nes s o f altered p e r ­ f o r m a n c e o f b e h a v i o u r leads to the in di vi du a l being placed at a d i s a d v a n t a g e relative to o th e r s in society. This brie f o u tl in e o f the d e v e lo p m e n t o f illness has been co n d en se d f r o m the In t e r n a t io n a l Class ification of Im pa ir m e nt s , Disabilities, and H a n d ic a p s . 6 Its relevance is th a t it helps to establish the f o u n d a t io n o f a conceptual mo del o f d i s a b le m e n t (F i gu re l) .5 Disease (or disorder) I Impairment (including functional limitation) \ Disability \ (activity restriction) \ I Handicap (disadvantage) Fig. 1. In brie f th en , im p a i r m e n t refers to d is fu n ct io n of b odi ly p a rt s o r or g an s . D isa bi lit y is a ch a ra c t e ri st i c o f an ind ivid ual , de scr ibi ng a b e r r a ti o n s in n o r m a l p e r ­ fo r m a n c e w h e th e r physical, e m o ti on al , m e nt al o r social. H a n d ic a p is th e social con se q ue n ce o f disability, i.e. the d is a d v a n ta g e c o m p a r e d with o th e r ind iv id ua ls .7 It is i m p o r t a n t to c o n si d e r h o w i m p a ir m e n t s and disabil iti es give rise to h a n d ic a p . Me d ic al a n d rem edi al tr e a t m e n t te n d s to c o n c e n t r a t e on the indi vidual, bu t d is a d v a n ta g e arises f r o m in t e ra c t io n with t h a t p e r s o n ’s s i tu at io n. T h is requi res t h a t t h o u g h t be given to the e n v i r o n m e n t , b o t h physi cal an d social, a n d to the resources to which the individual has access. T h e critical p r o p e r t y o f h a n d i c a p is its relativity, the d is co rd an c e betwe en the in d i v i d u a l ’s p e r f o r m a n c e a n d th e e x p e c t a ­ tio n o f his ‘soc ie ty ’.5 T a k i n g int o a c c o u n t the v a ri o us est ima tes o f dis­ ability, the ev ide nc e sugges ts t h a t a b o u t a t h i rd o f the p o p u l a t i o n is im p a ir e d in so m e way, a t h i rd o f th os e with im p a ir m e n t s ar e disa ble d to so m e e x te n t , and a th i rd o f th e la t te r ex pe ri en ce sufficiently severe res tri c­ ti on in activity as to be h a n d i c a p p e d . 5 N o w we c o m e to th e s i t u a t i o n fo u n d in d e ve lo p in g ru r a l areas. R U R A L D IS A B IL IT Y D u r i n g the I n t e r n a t i o n a l Ye ar o f D isabled Pe rs ons 1981, m a n y coun tries initiated surveys to est ablish m o r e a c c u r a t e figures o f th e n u m b e r s o f d is ab led people. In i n d u s t r i a l c o u n t r i e s , m a n y f a c t o r s we re e s t a b li s h e d re g a r d in g disability, e.g. th e as so cia ti on be tween dis­ ability and age. However, in the industrialized c oun tr ies it is recognized t h a t the available statistics are in ad e­ q u a t e a n d the re are still m a n y q ue st io ns which have not been answered. In d e ve lo p in g c o u n tr ie s still very little is k n o w n reg a r d in g the e x te n t o f the dis abil ity p r o b l e m as well as th e age and sex st ru c tu r e o f the dis abled p op u la t io n . E x t r a p o l a t i n g th e findings f r o m develo pe d cou ntries gives a n in d i c a ti o n o f the im m en s e re so ur ces w hic h will be needed to deal with the p r o b l e m over time, ta ki ng int o co n s i d e r a t io n t h a t d u r i n g the ne x t 50 years the p o p u l a t i o n o f the dev elo pi ng co u nt r ie s is exp ected to tr eb le .8 P r o p e r l y co n d u c te d dis abil ity surveys c o s t a gr eat deal o f mo ne y which develop ing c oun tr ies can ill afford. In a d d it io n , m a n y dev elo pi ng co u n tr ie s d o u b t , with reas on , w he th e r it is ethical to c o u n t disabilities w it h o u t offering tr e a tm e n t o r relief.8 A re ce n t I m p a i r m e n t Disab il it y a nd H a n d i c a p S tu dy in K w a Z u l u 9 w hic h o b ta i n e d i n f o r m a t i o n o n a sam pl e o f 1 659 p eo ple an d co st R20,000, gave an overall crude prevalence rate f o r m o t o r im p a ir m e n t o f 51 /1 000. The re was a m a r k e d increase with age, 6% were betw een 20- 40 year s, 27% were b etw een 40-50 years, an d 67% were over 60 years. T h e female age specific m o t o r im p ai rm en t rates fo r walk ing disability are given in T a b le 1. Table 1. Fem ale age-specific m o to r im pairm ent rates per 1000 for w alking disability Age M o to r impairment rate/1 000 0-10 13 11-20 15 21-30 26 31-40 36 41-50 86 51-60 96 >- 60 378 As ca n be seen ther e is a g r a d u a l increase in m o t o r i m p a i r m e n t ass oci ate d with w a lk in g disability with age and a d r a m a t i c increase over 50 years (277/1 000). T h e sa m e s t ud y sh ow ed a c r u d e prevalence rat e of 9 /1 000 f o r visual i m p a i r m e n t incl udi ng blindness. This was divided into 5/1 000 f o r blindness (vision less tha n 6 / 6 0 a n d 4/1 000 fo r visual im p a i r m e n t (vision between 6/2 9- 6 /6 0 ). Alth o ug h the rates were small in co m pa ri so n with th e m o t o r rates, it was si gnificant t h a t th e rat e for blin dne ss as a result o f m i c r o p h t h a l m u s was 2/1 000. ( M i c r o p t h a l m u s is a genetic c o n d i t i o n and the rat e in a n o r m a l p o p u l a t i o n is 0 ,5/ 1 000.) N o si mi lar studies using i m p a i r m e n t and disability as defi ned here hav e bee n d o n e in r u r a l a rea s a n d it is t h e r e fo re impo ssi ble to c o m p a r e disability a n d im p a ir ­ m e n t preva le nc e rates. H o we v er , this s t u dy d e m o n ­ intrinsic situation Exteriorized Objectified Socialized R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Physiotherapy, M ay 1986, vol 42 no 2 53 st rat ed th a t in a subsistence d e p e n d e n t ru ra l ar e a in S o u t h A fri c a w a lk in g dis abi li ty is a m a j o r pr o b l e m , an d t h a t blin dne ss a m o n g y o u n g peop le was mai nly d u e to a genetic c o n d i t i o n . 9 A c c o rd in g to surveys s p o n ­ sored by W H O , in so m e de ve lo pi ng co un tr ie s it has been es t im a te d t h a t bet we en 7 an d 10 p er ce n t o f the p o p u l a t i o n in these co u n tr ie s is dis abl ed. D isa b le d p e r ­ son s f o r m th e m o s t severely u n d e rp r iv il eg ed g r o u p in the societies o f dev elo pi ng c o u n t r i e s . 10 W H O has rec o g­ nized t h a t . . th e massive dis abi li ty is, clearly, in d e v el o pi ng c o u n t r i e s ’,6 a n d W il s o n 8 st a te d t h a t ‘It is am o n g the p o o re s t c o m m u ni ti es in the develop ing c o u n ­ tries th a t po ve rt y breed s d i s a b le m e n t a n d d is ab le m en t breeds poverty, a vicious circle th a t the p o o r e r coun tries ca n least affo rd. Th ese c o m m u n it ie s are the tar ge t of every r a t io n a l d e v e lo p m e n t p r o g r a m m e — u n d e r p r iv i­ leged, u nd er s er ve d , u n d e r n o u r is h e d , a t the b o t t o m o f every e c o n o m i c a n d social he ap. Diseases long c o n ­ trolled elsewhere still flourish an d bri ng with th e m not only d e a th b u t lifelong disability, e.g. leprosy. R es our ces f o r heal th ca re are still scarce in mos t dev elo pi ng co u n tr ie s. T hi s is especially tr u e in rural are as w here, in m a n y c ou n tr ie s, ± 80 pe rc e n t o f the p o p u l a t i o n live. In SA th e 1970 censu s in d ic at ed th a t 70% o f the SA bl ack p o p u l a t i o n live in h o m e l a n d and wh ite f a r m a re a s (i.e. r u r a l ) . 11 R e h a b il it a ti o n services are a m o n g the least developed and it has been calculated t h a t 98 p er ce n t o f the d is a bl e d hav e no access to services in thei r lifetime. F o r th os e few w h o no w receive services, these ar e ma in ly in th e f o r m o f insti tut ion - based reh ab i li ta t io n (1BR). 1BR is c o n c e n t r a t e d in the cities a n d o nl y o n ra r e occas io ns av ail abl e to ru ra l p o p u la t io n s . In s tit u ti on s are highly specialized and expensive. T he y are d ep en d e n t fo r efficient r u n n i n g on tea m s o f highly tr ai n ed pro fe s­ sionals w h o w o r k a c c o rd i n g to W e s t e rn st a n d a rd s . T h ei r m e t h o d s incl ude use o f s o p hi st ic at e d tec hnology. I ns tit ut io ns are usua lly res iden tial a n d r eq u ir e a g rea t n u m b e r o f staff. P la n s to e x te n d IB R in o r d e r to co v er p o p u l a t i o n needs hav e usu a lly m e t with e c o n o m i c p ro b le m s. An attit ud e c o m m o n ly fou n d is th a t services fo r the disabled are a lu xur y o nl y a rich c o u n t r y ca n a f f o r d . 10 All this has in di cat ed t h a t a di ff er en t a p p r o a c h is requ ir ed with re g ar d to r e h a b i li ta t io n in dev elo p in g rur al areas , and SA is co n si d er ed a d e v e lo p i n g co un tr y. It is ev id en t t h a t the c o n v e n t i o n a l a p p r o a c h in which dis abilities were div id ed in t o i m p a i r m e n t cate gor ies , e.g. Physical, D eaf , Blind, M e n t a l r e t a r d a t i o n , etc. is n o t a p p r o p r i a t e in r u r a l a re as a n d t h a t a m ul ti -d is ci p­ linary a p p r o a c h is re qu ir ed . It is n o t on ly th e a p p r o a c h to the disability p r o b l e m wh ich m us t be multi-discip- linary b u t also to th e n e x t c o n c e p t which I w o ul d now like to in t ro du c e; t h a t o f C o m m u n i t y - b a s e d R e h a b il it a ­ tion (CBR). C O M M U N IT Y -B A S E D R E H A B I L I T A T IO N (C B R ) C B R is a c o n c e p t closely re l a te d to p r i m a r y he a lth care an d fo r m s an in te gr al p a r t o f the p r o g r a m m e to develop he a lth fo r all by the y ea r 2000. ‘C o m m u n i t y - b a s e d re h a b i li ta t io n involves meas ure s ta k e n a t th e c o m m u n i t y level to use a n d bu il d on t h e r e s o u r c e s o f t h e c o m m u n i t y , i n c l u d i n g th e i m p a ir e d , d is ab le d , an d h a n d i c a p p e d pe rs o ns t h e m ­ selves, th ei r families, a n d thei r c o m m u n i t y as a w h o l e . ’10 C B R p ro m o te s c o m m u n i t y res ponsibility an d reliance on local reso urce s. F a m i ly a n d c o m m u n i t y m em b er s are involved in th e ess ential t r a in i n g f o r th e ir ow n d is ab le d , u si ng local te ch n o l o g y . A refe rra l sy st em is set up to m eet needs t h a t c a n n o t be locally d e a lt with. T o m a k e it effective, tr ai n i n g is d o n e in the fol lowing way. R e h a b i l i t a t i o n p r o g r a m m e s o f p r o v e n v a l u e a r e c h o s e n a n d th e s e a r e b r o k e n d o w n i n t o m o d u l e s , a r r a n g e d in so called ‘tr a i n i n g p a c k a g e s ’ (T P s) . T P s include a shor t description fo r the person w ho introduces an d super vises the tr ain in g, a detailed d es cr ip ti o n of t he v ar i o us tr a in i n g steps a n d an e v a lu a tio n sheet. T he la n g u a g e is si mp le a n d the te x t s u p p o r t e d by m a n y d ra w in g s . T h e T P s are given dir ectly to the d is ab led p e rs o n an d to th e fam ily m e m b e rs res pon sib le fo r the daily training. C R B is c arr ied o u t in the fol low ing ma nn er : A ‘local s u p e r v i s o r ’ is r ec r u it ed f r o m th e c o m m u n i t y an d tr a in e d. T h e local s u p e r v is o r identifies the di sa bl ed by m a k i n g h o u s e - to - h o u s e visits. T h e d is ab led an d t h e i r families ar e m o t iv a t e d to ta k e p a r t in C B R . A ‘t r a i n e r ’, n o r m a ll y a fam il y m e m b e r o f the disa ble d o r a fr ie n d, receives in s tr u c t io n s on h o w to d o the train in g. P ra c t ic a l d e m o n s t r a t i o n s are given a n d th e local s u p e r ­ vis or check s t h a t th e t r a in i n g is d o n e co rrectly. T h e results are e v a lu a te d t o g e t h e r w ith the d is a bl e d an d the t r a i n e r . 10 T h e m o d u l es used in C B R have been co m p i le d int o a W H O m a n u a l ‘T r a in i n g the D isa bl ed P e r s o n in the C o m m u n i t y ’. 12 T h e m a n u a l c o n ta i n s b o o k le t s fo r 6 g r o u p s o f d is ab le d pers ons; i.e. those w h o have fits, h e a ri n g an d speec h difficulties, le ar nin g difficulties, mo v i n g difficulties, seeing difficulties, a n d pe rs o n s with st ra n g e b e h av io ur . E a c h m o d u l e c o n ta in s the a p p r o ­ p ri at e T P s , in s tr u c t io n an d ev a lu a ti o n sheets. In a d d i ­ ti on , th e r e are f o u r guides: f o r policy m ak er s a nd p la n n e r s , f o r local su per vis or s, f o r c o m m u n i t y leaders, an d f o r teachers. N o w is this a p p r o a c h feasible in SA? C B R has been u se d in d if fe re nt p a r t s o f th e w or ld , e.g. B o ts w an a, Bu rm a, India, Mexico, Nigeria, Pa ki s ta n , the Phillipines, S a i n t L u c ia (C a r i b b e a n ) , a n d Sri L a n k a . It has been p ro v en to be technically viable, effective, feasible, and a p p r o p r i a t e in all th e d if fe re nt settings in which it has been used. It has been e s t im a te d to be ec o n o m i c al l y m a i n t a i n a b l e a n d o rg a n i z a ti o n a ll y feasible if im p le ­ m e n t e d as a c o m p o n e n t o f p r i m a r y he al th ca re an d c o m m u n i t y services. T h e m a n u a l has been a d a p t e d an d an im p ro v e d vers ion was pu b lis h ed in 1983. T h e SA Fe d e ra l C o u n c il fo r R e h a b il it a ti o n o f the D is ab l e d has t a k e n the initiative by b e c o m i n g involved in a p il o t p ro j e c t wh ich it is h o p e d will c o m m e n c e in R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 54 Fisioterapie, M ei 1986, dee! 42 no 2 1986 in K w a Z u l u . F u n d i n g ha s been m a d e av ail ab le by th e A n g l o - A m e r i c a n C h a i r m a n ’s F u n d fo r th e a d a p t a ­ tio n o f the W H O M a n u a l to local r u r a l c o n d it io n s in K w a Z u lu a n d for it to be tr an sl at ed in t o Zulu. T h e m a n u a l will inclu de, in its d e v e lo p m e n t, the testing o f the m a t e ri a l on T h e r a p y A t t e n d a n t s w h o have been involved in de al in g with rur al dis ab ility fo r 5 years a t M a n g u z i Ho spita l. T h e c o n c e p t o f R e h a b i l i t a t i o n A ssi sta n ts is the final one wh ich I w oul d like to deal with in this paper. R E H A B I L I T A T IO N T H E R A P I S T S Ir win (1982) p r o p o s e d the use o f p a ra p r o fe s s i o n a l w or ke rs, ba ck e d by specialized g o v e r n m e n t facilities, to pr o v i d e th e basic services, fo r dis abi li ty p re v e n t io n and c o m m u n i t y based re h a b i li ta t io n . Ideally, he stressed t h a t these c o m m u n i t y level w o rk e rs s ho ul d c o m e fro m the ar eas in w hic h they w o rk . T h e y s h ou ld be tra in ed to w o r k in th ei r o w n villages o r ar eas a n d th us , they w o ul d have to a n s w e r directly to th ei r c o n s t it u e n c ie s . 13 T h e n a m e given to the w o r k e r u n d e r di sc us si o n is a R e h a b il it a ti o n T h e ra p i st . It is the acc epted te rm fo r a n o n - p r o fe s s i o n a l w o r k e r involved with reh ab i li ta t io n an d sup ervised by a pr of es si on al t h e r a p i s t . 14 In K w a Z u l u a fo u r- ti er e d reh ab i li ta t io n delivery sys­ te m fo r r u r a l he a lt h services has been p r o p o s e d (F ig u re 2). Dept of Health Control Therapy Post Referral Hospitals 10 Physio 10, OT 3 Speech Therapy Supervisors Outlying Rural Hospitals 1 Rehabilitation Therapist Community Local Supervisors/Comm unity Health W orkers/Trainers Fig 2. Proposed four-tiered rural rehabilitation delivery system. P ro g r es s to w a r d s success in the p re v en t io n o f dis­ a bi li ty a n d in th e deli ver y o f r e h a b i li ta t io n to tho se at risk in r u r a l a r e a s will r eq ui re si gnificant c h an ge s in est ablished habits. P eo p le ev erywhere resist change. It m u s t be u n d e r s t o o d t h a t new a p p r o a c h e s are one th i n g b u t new p r o g r a m m e s are a n o t h e r a n d t h a t the p r o g r a m m e s will o n ly be a c ce pt ed if th er e is a clear u n d e r s t a n d i n g a n d in v o l v e m e n t on th e p a r t o f all the g r o u p s a n d o f th e in di v id u al s at risk. C o m m u n i t y p a r t i c i p a t i o n is ess en tial an d only possible w h er e the pro cesses o f p la n n i n g a n d a d m i n i s t r a t i o n a re d e c e n ­ trali zed to th e c o m m u n i t y level — th e c ha lle ng e is to ident ify , u n d e r s t a n d a n d w o r k with the e xi s tin g c o m ­ m u n i ty s y s te m s .13 ‘In its fullest sense, c o m m u n i t y p a rt ic i p a ti o n is the m e t h o d o f all ow in g peop le to m a r s h a l a n d ch ann el th ei r en ergies a nd abilities to im p r o v e th ei r lives. It requi res o rg a n i z a ti o n an d m o t iv a tio n; and the o u t ­ s i d e r ’s role is to cajo le an d inspire, to e n c o u r a g e the c o m m u n i t y to tak e the initiative. W he n c o m m un iti es begin to u n d e r s t a n d w h a t cau ses disabilities a m o n g th em , they will be the first to need to develop activities to bring a b o u t p r e v e n t io n . ’13 With regard to professionals and organi zatio ns serving th e dis abl ed, it is essential th a t they u n d e r s ta n d , accept, an d involve themselves in the proces s o f simplifying the m a n p o w e r s t ru ct u r e in reh ab il ita ti o n services. T h e costs o f he a lt h care services have reache d a level th a t re d u c ­ tio ns will have to be m a d e w h e t h e r we like it o r not. T h e professionals mus t be willing to discuss and pre par e themselves fo r the fu tu re ch an ge s and these chang es will the n be less t r a u m a t i c . 15 C O N C L U S IO N 1 am su re there is no d o u b t in y o u r mi nd s a b o u t the need to change. We have posed the ques tion , ‘Is R e h a b i­ lita ti on o f the R u r a l D isa bl ed a realistic ob je c tiv e’, t r u st th a t it has been answ ere d in the affirmative. However, we need im agination, courage, perseverance, and abov e all, fai th in the ideal of p r o vi di n g R e h a b il it a ­ t i o n fo r All ( R F A ) . T h e R F A p h il o s o p h y stresses the right to reh a b i li ta t io n an d its r e l at io n sh ip to the right to self-sufficiency. It demystifies the r e h a bi lit at io n p r o ­ cess an d places it in the ha nd s o f disabled people themselves. As W o r l d H e a l t h p o in t s o u t in th e ir M a y 1984 J o u r ­ n a l , 16 ‘No single a p p r o a c h to a R F A p r o g r a m m e — i n cl u di n g tec hn ol og y, delivery system an d m a n a g e m e n t — w o u ld be a p p li ca b le to every c o r n e r o f the eart h. E a c h c o u n t r y s ho ul d de sign its o w n plan , based on ex p er i en ce fr o m a b r o a d a n d lessons lear ned at home. R F A has so fa r been in t r o d u c e d in a b o u t 25 coun tr ies . T o d a y it cov ers to t a l p o p u l a t i o n s o f m or e t h a n a million people. It requi res only a fr ac ti o n o f the budg et needed fo r tr a d it io n a l in st it ut io na l rehab il it at ion . D e a t h and illness have always occup ied the health au th o r it ie s b ut the third d im en si o n — disability — has yet to a t t r a c t the a tt e n ti o n it deserves. It has been said t h a t the q u a li ty o f life am o n g d is a bl e d pe rs o ns in dev elo p in g co u n tr ie s is a m a t t e r of g r e a t c o n c e r n to the i n t e r n a t i o n a l c o m m u n it y . And here in S o u t h Af ri ca the initiative to im p ro v e the q u a li ty o f life o f th e ru ra l disa ble d has been ta k en up by th e S A N a t i o n a l C o u n c il fo r the Blind, a n d the Fe der al C ou nc il for R e h a b il it a ti o n o f the Disabled. 1 h o p e th a t my p a p e r has e m ph as is e d the im p o rt a n c e o f s u p p o r t i n g the initiative and has aff irm ed t h a t by using the C o m m u n i t y Based R e h a b il it a ti o n A p p ro a c h , R e h a b il it at io n o f the R u r a l D isabled is a realistic objec­ tive. References used in the Preparation o f this Paper 1. W H O Technical Report Series No. 497, Geneva 1972. 2. WH O, Disability prevention and rehabilitation. WH O A29/ I n f D o c / 1.28 April 1976. 3. WHO, Disability prevention and rehabilitation. Report of the W H O Expert Committee on Disability Preven- R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) physiotherapy, M ay 1986, vol 42 no 2 55 tion and Rehabilitation. W H O Technical Report Series 668. W H O, Geneva, 1981. 4. Rep ort of a meeting of experts, International Society for Rehabilitation of the Disabled, Ireland, September !969. 5. Wood P H N . Prospects for Control. In: Disability Prevention: the Global Challenge (ed. Sir Jo h n Wilson). Oxford University Press, Oxford 1983. 6. W H O International Classification of Impairments, disabilities, and handicaps. WH O, Geneva 1980. 7. W H O Regional Office for Europe. The Age Factor. In: Disability Prevention: A Global Challenge (Ed. Sir J o h n Wilson). Oxford University Press, Oxford 1983. 8. Wilson Jo hn. The scale of the problem. In : Disability Prevention: A Global Challenge (Ed. Sir Jo hn Wilson). Oxford University Pres, Oxford 1983. 9. McLaren PA, Gear JS S, lrwig LM. Prevalence of motor impairment and disability in a rural community in KwaZulu (in preparation). 10. W H O C o m m u n i t y Based R e h a b i l i t a t i o n . W H O RH B /1 R / 8 2 .1 . Report of the W H O lnter-regional Consultation Sri Lanka, July 1982. 11. SA Institute of Race Relations 1978: A survey of race relations in SA, Johannesburg. 12. Helander E, Mendis P, Nelson G. Training disabled people in the community. A manual for community based rehabilitation for developing countries. Geneva, W H O 1983. 13. Irwin Michael HK. Delivery and community partici­ pation. In: Disability Prevention: the global challenge (Ed. Sir John Wilson) Oxford University Press, Oxford 1983. 14. W F O T (World Federation of Occupational Th era ­ pists). Guidelines for the Development of Curricula for the Education of Rehabilitation Therapists in Developing Countries. (Unpublished document pre­ pared by W F O T Education committee) 1980. 15. W H O Chronicle 31, p. 492. 16. W H O Rehabilitation for all. World Health, May 1984. A dditional References R elating to R ural Disability Editorial. Disability: Prevention or containment. Interna­ tional Jo ur n al of Epidemiology 1981; 11: 1:3-4. I Chitti Babu A. Rural rehabilitation — must it remain a the or eti cal ideal? R e h a b il it at io n in Asia 1980; x x l : 4.38-40. Dick B, Spencer IWF, Watermeyer GS, Bourne DE, Wolff IMF, Moyle GD. Chronic disease in non-institutionalized persons, P a rt 11, Who cares? S Afr Med J 1978; 53: 918-936. Hamme rma n Susan R. Dealing with disability in the deve­ loping world: the paradox. World Health 1981; 4-5. Joh nsto n Mary. The planning dialogue in the community. Contract; February 1978. Gaston Don. Low cost aids, appropriate health resources and technologies, Action G roup Ltd. A R H T A G London 1982. Marghulec 1, Spira E. An ap pr oac h to the detection of the disabled in a rural area. In: Lees D and Shaw S (eds.). Impairment, disability and handicap. Heinemann E du ca­ tional Books, L on don 1974; pp. 65-77. M en on PKJ. Light in the darkness. World Health, April 1982; pp. 27-29. Mia Ahmadallah, Islam Hafizul, Ali Shamsher. Situation of handicapped children in Bangladesh. Assignment Chil­ dren, 53/54, Spring 1981; 199-217. Buthelezi Commission; the requirements for stability and development in KwaZulu and Natal, Vol. I and 2. H & H Publication Dur ba n, 1982. Swart H HJ . Die huidige situasie ten opsigte van die p ra k ­ tiese hantering van blindheid in Suid-Afrika. SA Mediese Tydskrif 1981 November. Su tter EE, Ballard RC. A C om m un it y ap pro ach to T r a ­ ch o m a control in the Northern Transvaal. S Afr Med J April 1978; 53: 622-625. McLa ren PA. Rural em ployment of the handicapped in Southern Africa. Pap er read in conjunction with William Rowland at the Conference of the S.A. Federal Council for Rehabilitation of the Disabled Swaziland June 1983. McLaren PA. Motivation for training o f multipurpose rehabilitation therapists. Pape r read at the SA Congress for people with disabilities, Dur ban , September 1984. McLaren PA. The need for a resource d ocu me nt for starting projects for disabled in rural areas. Paper read at the SA Federal Council for Rehabilitation of the Disabled, Joha nn es bur g, August 1984. McLaren PA. T owards emp loyment for rural blind in KwaZulu. I M F A M A 1982; 22: 6. McLar en PA. The prevalence and impact of m o to r and ocular, disability and im pairment in a rural community, and the implications for rehabilitation. Pap er presented to the SA Association of Occupational Therapists C o n ­ gress, Cape Town, July 1985. Pillay PN. The distribution of medical ma npower and health care facilities in Sou th Africa. Carnegie C o n ­ ference Paper No. 167, Cape Town 1984. Rehabilitation International, childhood disability: its pre­ vention and rehabilitation. Assignment Children 1981; 53/54: 43-75. Sebina David B, Kgodidinintsi Adelaide Darling. Disability prevention and rehabilitation in Botswana. Assignment Children 1981; 53/54: 135-152. Sene Pape Marcel. The African experience. World Health 1982. Sutter EE, Ballard RC. Comm unity participation in the control of T ra ch om a in Gazankulu. Soc Sci Med 1982; 17(22): 1813-1817. The Thusanani Association. Venda South Africa. Report, April 1984-March 1985. Wong Wah Tomp ar- Tiu , A u ro ra P. A community pr o ­ gram me in the Phillipines. Assignment Children 1981; 53/54: 165-183. Rehabilitation for all. World Health 1984; May: 1-31. W H O. The training and utilization of auxiliary personnel for rural health teams in developing countries. Report of a W H O Expert Committee. W H O Geneva, 7-35. WH O. Towards a multipurpose rehabilitation therapist. W H O presentation (unpublished document). United Nations. World pro gramme of action concerning disabled persons. United Nations Decade of Disabled Persons 1983-1992. New York 1983. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )