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Barriers to the rehabilitation of the handicapped in Nigeria
Publ. Hhh, Lond. (1981) 95, 82-86
Barriers to the Rehabilitation of the Handicapped in Nigeria A. O y e m a d e MD. (Glas,). D.P.H (GJas.). D.T.H. (lb.) a n d A. O l u g b i l e M.B,. Ch,B.. ,D.P,H_ D.I.H.. M.R.C.P,
Deparzment of PrevenZive and Social Medicine. University College Hospital, /badan, Nigeria
In recent years there has been an increasing awareness in Nigeria of the need to help the handicapped lead an independent life. Such rehabilitation processes have however been greatly hampered by some social factors. This paper highlights some of these factors, which include povc~'ty, ignorance, prejudice, cultural beliefs and practices. It is suggested that some of these ,~oeial barriers carl be removed by giving guidance and supportive measures to the families o f the disabled and also by the introduction of an effective social security scheme. In addition, the attitude towards the handicapped can be greatly improved by educating the community as to the true causes of handicaps. Introduction According to Stolov, I the twentieth century saw a shift in traditional medicine from treating diseases to treating the patient, and rehabilitation focuses on the patient in relation to others, especially to the family and the community. M a n y physicians now recognize that medical care cannot be considered complete until the patient with the residual disability has been trained to live and to work with what he has left. Rehabilitation therefore concerns itself with the recognition o f the dignity o f man, the importance o f the individual and the need for a combined effort to reintegrate the disabled person in his society. In Nigeria, infective and parasitic diseases constitute the m a j o r health problems, 2, 3 and for m a n y years the control o f such diseases had so engaged the attention of the medical profession that very little attention was paid to the welfare o f the handicapped. In recent years, however, there has been an increasing awareness on the part of the .government and the c o m m u n i t y of the need to assist this category o f persons to lead an independent life. a Unfortunately, such attempts a t rehabilitation have been greatly hampered by some social factors prevailing in the society. In this paper, some o f these social barriers are discussed, and illustrated where possible with case histories. Case 1 M.A. was a y o u n g man aged 25 years, married with a 10-month-old baby. He had been an employee o f a cement factory for 2 years 4 months and was reported to be a daily paid worker w h o dealt mainly with electronic installations in the factory. H e was first seen at the University College Hospital, Ibadan with severe burns o f both hands and feet which 0033-3506/81/020082+05 $01.00/0
© 1981 The Society of Community Medicine
Nigerian Handicapped Rehabilitation
83
were sustained at home from accidentally touching the overhead mains with a pole in an attempt to adjust his television aerial. After careful examination, it was feared that both hands and feet, which were becoming gangrenous might have to be amputated. However, with intensive medical care the feet were saved but both hands had to be amputated. He was later provided with locally made artificial hands which soon proved to be ineffective as they were badly fitted and consequently were non-functional. The patient, who could only depend on the nurses for activities of daily living like bathing, toileting and feeding became so depressed that a medical social worker had to be invited to discuss his problems with him. H e was encouraged to express his feelings and anxieties at the loss of his limbs and about hishopes for the future. It was then gathered that he came from a poor family and, but for the financial assistance of his company, he would not have been able to pay the cost of the artificial limbs and his hospital expenses. Besides, he had to depend on relatives and friends to provide food and shelter for his family and if the situation continued, he feared his young wife might leave him. Mr M.A. had once made an appeal for donations towards his rehabilitation abroad where there are better medical facilities, but the response had not been favourable. H e expressed the wish to set up a small business ofhis own selling electronic parts for which he would require at least 1000 naira (£500 sterling). As his relatives could not provide such an amount and the publicity had failed to give him financial support, he feared he might become a liability to his family for the rest of his life. Meanwhile, he is stil~ a patient in the hospital, where he continues to be nursed and cared for by the hospital staff. Economic poverty is a fact of life for most handicapped persons regardless of their cultural heritage. In Nigeria the poor disabled person not only lacks the means to pay for the needed medical care, appliances and transportation, but most find it difficult to get suitable employment. This case is one of several in our society demonstrating the plight o f many handicapped persons for whom very little can be done due to financial constraints and inadequacy o f medical facilities. Case 2
A.A. was an l l-year-old boy who was almost crippled with a chronic ulcer and flexion deformity of the right knee. His father had died, and because o f the condition of the boy the 'father's relatives had not taken kindly to the mother and eventually forced her out of her matrimonial home. The boy was however allowed to stay with his paternal uncles but was soon sent to join his mother when his condition deteriorated. The child was immediately admitted to a hospital for treatment and although his condition improved but very slightly, he had to be discharged after a year as the mother who had since remarried and was expecting a baby could no longer support him and the stepfather did not take any interest in his welfare. Consequently, the child left home and decided to earn his living as a beggar. Fortunately, one of the hospital ambulance drivers who had known the boy at the hospital as a patient recognized him as he was begging for alms at the roadside. The driver picked him up and took him to the Medical Social Workers" Department of the University College Hospital Ibadan and later traced his mother and paternal uncles. One of the medical social workers went home with the boy to persuade his mother and some other relatives to help him financially. The family responded favourably and made substantial contributions to the cost o f his hospital care. He is now making good progress; the ulcer has almost healed and arrangements are being made to have him admitted for surgery on his right knee. The social workers continue to encourage the family not to relax their efforts in caring for the boy, who apparently is very happy and looks forward to going back to school. Ofparticular interest to social scientists are attitudes which are unfavourable to one group
84
O. O vemade and A. Olugbile
or the other. In Nigeria, the child represents the family's position in the society and a defective child is regarded as having brought shame on the family. In Case 2, the mother of the boy was forced out of her matrimonial home because of her child's condition and the boy's relative including his stepfather were not interested in his welfare. The boy would have been reduced to a life of beggary like many others in o u r big cities but for the intervention of the "good samaritan ", the hospital ambulance driver. Apart from attitudes, the cultural beliefs also constitute a social barrier to rehabilitation. In most African societies, illness and physical defects are considered as a punishment or a curse for some wrongdoing? Such beliefs have often generated a feeling of guilt and unfavourable altitude towards the handicapped so that the child is often rejected, as shown in this case history. Case 3
R.I. was a 36-year-old-labourer in the warehouse of a tobacco company where he had been an employee for 3 years. He sustained a severe head injury in a road tralfic accident as a result o f which he remained unconscious for 3 months. He received intensive medical care in a hospital and was subsequently discharged after about 6 months. Soon after he resumed duty, he was found unconscious and had to be given emergency treatment at the factory clinic. He suffered from two further s~,milarattacks at elose intervals, and after thorough medical investigation a diagnosis of epilepsy was established and he was immediately started on treatment. His case was later reviewed by the company doctor who recommended that he should be transferred from the warehouse which involved working at heights to a less risky job and one that carried lower status, but with the assurance that his salary would remain the same. R.I. did not take kindly to this decision as he was convinced that his health problem, which he believed was due to an act ofwitchcraft inflicted on him by his former employer, could not be solved by a medical doctor. He expressed the hope, however, that his health would soon improve with the help of a local herbalist under whom he was receiving treatment and in whom he had great faith. Thus he failed to see the need for redeployment and continues to work under conditions which constitute a danger to his life. In Nigeria and indeed in most African societies, witchcraft is a reality, a belief which is very prevalent among literates and illiterates. 6 Disabilities, illnesses or any misfortune are attributed to acts of witchcraft and most people resort to native herbalists for solution to such problems. Thus proper medical treatment is often delayed. In Case 3, the man refused to take the advice of the company doctor because of his strong belief that his illness was not due to any clinical pathology but to the bad spell cast on him by his former employer. He therefore resorted to treatment by the native doctor and refused to be redeployed to a more suitable job. Finally, religion which is part of culture is a social problem in the rehabilitation of the handicapped. Most Nigerians are of Islamic faith. 7 This religion accepts beggary by the handicapped as a way of life and encourages the free giying of alms to such unfortunate people. Consequently, many who are only slightly handicapped and who could otherwise be gainfully employed parade the streets begging for alms. This paper has highlighted some o~f the social barriers to the rehabilitation of the handicapped in Nigerian society, and these include poverty, prejudice, cultural beliefs and practices. In any attempt to remove some of these social problems, it is suggested that the community be properly educated as to the true concept of health and disease, and it is hoped that such knowledge will lead to better understanding of the causes of various types o f handicaps and to improved management of such conditions.
Nigerian Handicapped ~Rehabilitation
85
Figure 1. Four blind beggars b y the side of a street in lbadan.
The family of the handicapped must not only be encouraged to accept the disability without necessarily raising in them false hope of absolute cure, but they must also be given guidance as well as moral and financial support. In the developed countries, handicapped persons are well catered for under the various social security schemes.~-1° In Nigeria, however, apart from the National Provident Fund Act o f 1961 which provides but a mere token compensation for injuries sustained at work, there is no other statutory provision for the handicapped. As our medical services continue to improve, so will the survival rate of children born with one form of handicap or the other. In addition, the recent rapid process of urbanization and industrialization is likely to expose more people to the risk of being maimed through accidents on the roads and in industries. These factors will inevitably increase the number of handicapped persons in our society. There is therefore an urgent need to establish a national social security scheme under which the government, the community and the voluntary organizations can work together to provide adequately for the many handicapped whose only means of livelihood is beggary (Fig. 1). Lastly, it is not enough to establish rehabilitation centres; it is equally important that they must be staffed with persons who have had training in the making and fitting o f appliances for the various types of handicap. Such measures will not only make expensive trips abroad unn~essary, but will also ensure that more handicapped persons are assisted to lead a more independent life if suitable appliances can be obtained locally and at relatively lower costs.
Acknowledgements The assist~mce of Mrs Omitowoju and Sister Catey of the Medical Social Worker's Department, U.C.H., Ibadan is gratefully acknowledged.
86
O. Oyemade and A. Olugbile References
I. Stolov, W. C. (1966). Rehabilitation and Medicine, S. Light (Ed.) Baltimore, Maryland: Waverley Press. 2. Gilles, H. (1964). Akufo - An Environmental Stud)" of a Nigerian Village Community. University of lbadan Press. 3. Ministry of Health Bulletin. (I 978). An Annual Statistical Btdletin of Ihe Epidemiological Unit. Oyo State of Nigeria. 4. Oyemade, A. (1975). Roy. Society oftteaith Journal 95. 282. 5, Amadi, V. (1980). Beliefs about causes of Disabilities in Nigeria: Implicationsfor the Management and Adjustment of the Handicapped Child in Home. Paper read at an International Conference on Cerebral Palsy on 16--19 January 1980. Universily of Ibadan, Nigeria. 6. Awolalu, Omosade, J. (1979). Jroruba Beliefs and Sacrificial Rites. Great Britain: Lowe and Brydone Press. 7. Nigeria Census (1963). In Population Census of Nigeria (1963). 8. Somers, H. M. & Somers, A. R. (1954). Workmen's Compensation; Prevention Insurance and Rehabilitation of Occupational Disability. New York: John Wiley and Sons. 9. Clark, D. W. & Machahon, B. (1967). t~reventive Medicine. Boston, London: Little Brown and Company. 10. Davies-Meredith, J.B. (1974). Preventive Medicine, Comnlun#y Health and Social Services. Billings and Sons Ltd. Press.
Barriers to the Rehabilitation of the Handicapped in Nigeria A. O y e m a d e MD. (Glas,). D.P.H (GJas.). D.T.H. (lb.) a n d A. O l u g b i l e M.B,. Ch,B.. ,D.P,H_ D.I.H.. M.R.C.P,
Deparzment of PrevenZive and Social Medicine. University College Hospital, /badan, Nigeria
In recent years there has been an increasing awareness in Nigeria of the need to help the handicapped lead an independent life. Such rehabilitation processes have however been greatly hampered by some social factors. This paper highlights some of these factors, which include povc~'ty, ignorance, prejudice, cultural beliefs and practices. It is suggested that some of these ,~oeial barriers carl be removed by giving guidance and supportive measures to the families o f the disabled and also by the introduction of an effective social security scheme. In addition, the attitude towards the handicapped can be greatly improved by educating the community as to the true causes of handicaps. Introduction According to Stolov, I the twentieth century saw a shift in traditional medicine from treating diseases to treating the patient, and rehabilitation focuses on the patient in relation to others, especially to the family and the community. M a n y physicians now recognize that medical care cannot be considered complete until the patient with the residual disability has been trained to live and to work with what he has left. Rehabilitation therefore concerns itself with the recognition o f the dignity o f man, the importance o f the individual and the need for a combined effort to reintegrate the disabled person in his society. In Nigeria, infective and parasitic diseases constitute the m a j o r health problems, 2, 3 and for m a n y years the control o f such diseases had so engaged the attention of the medical profession that very little attention was paid to the welfare o f the handicapped. In recent years, however, there has been an increasing awareness on the part of the .government and the c o m m u n i t y of the need to assist this category o f persons to lead an independent life. a Unfortunately, such attempts a t rehabilitation have been greatly hampered by some social factors prevailing in the society. In this paper, some o f these social barriers are discussed, and illustrated where possible with case histories. Case 1 M.A. was a y o u n g man aged 25 years, married with a 10-month-old baby. He had been an employee o f a cement factory for 2 years 4 months and was reported to be a daily paid worker w h o dealt mainly with electronic installations in the factory. H e was first seen at the University College Hospital, Ibadan with severe burns o f both hands and feet which 0033-3506/81/020082+05 $01.00/0
© 1981 The Society of Community Medicine
Nigerian Handicapped Rehabilitation
83
were sustained at home from accidentally touching the overhead mains with a pole in an attempt to adjust his television aerial. After careful examination, it was feared that both hands and feet, which were becoming gangrenous might have to be amputated. However, with intensive medical care the feet were saved but both hands had to be amputated. He was later provided with locally made artificial hands which soon proved to be ineffective as they were badly fitted and consequently were non-functional. The patient, who could only depend on the nurses for activities of daily living like bathing, toileting and feeding became so depressed that a medical social worker had to be invited to discuss his problems with him. H e was encouraged to express his feelings and anxieties at the loss of his limbs and about hishopes for the future. It was then gathered that he came from a poor family and, but for the financial assistance of his company, he would not have been able to pay the cost of the artificial limbs and his hospital expenses. Besides, he had to depend on relatives and friends to provide food and shelter for his family and if the situation continued, he feared his young wife might leave him. Mr M.A. had once made an appeal for donations towards his rehabilitation abroad where there are better medical facilities, but the response had not been favourable. H e expressed the wish to set up a small business ofhis own selling electronic parts for which he would require at least 1000 naira (£500 sterling). As his relatives could not provide such an amount and the publicity had failed to give him financial support, he feared he might become a liability to his family for the rest of his life. Meanwhile, he is stil~ a patient in the hospital, where he continues to be nursed and cared for by the hospital staff. Economic poverty is a fact of life for most handicapped persons regardless of their cultural heritage. In Nigeria the poor disabled person not only lacks the means to pay for the needed medical care, appliances and transportation, but most find it difficult to get suitable employment. This case is one of several in our society demonstrating the plight o f many handicapped persons for whom very little can be done due to financial constraints and inadequacy o f medical facilities. Case 2
A.A. was an l l-year-old boy who was almost crippled with a chronic ulcer and flexion deformity of the right knee. His father had died, and because o f the condition of the boy the 'father's relatives had not taken kindly to the mother and eventually forced her out of her matrimonial home. The boy was however allowed to stay with his paternal uncles but was soon sent to join his mother when his condition deteriorated. The child was immediately admitted to a hospital for treatment and although his condition improved but very slightly, he had to be discharged after a year as the mother who had since remarried and was expecting a baby could no longer support him and the stepfather did not take any interest in his welfare. Consequently, the child left home and decided to earn his living as a beggar. Fortunately, one of the hospital ambulance drivers who had known the boy at the hospital as a patient recognized him as he was begging for alms at the roadside. The driver picked him up and took him to the Medical Social Workers" Department of the University College Hospital Ibadan and later traced his mother and paternal uncles. One of the medical social workers went home with the boy to persuade his mother and some other relatives to help him financially. The family responded favourably and made substantial contributions to the cost o f his hospital care. He is now making good progress; the ulcer has almost healed and arrangements are being made to have him admitted for surgery on his right knee. The social workers continue to encourage the family not to relax their efforts in caring for the boy, who apparently is very happy and looks forward to going back to school. Ofparticular interest to social scientists are attitudes which are unfavourable to one group
84
O. O vemade and A. Olugbile
or the other. In Nigeria, the child represents the family's position in the society and a defective child is regarded as having brought shame on the family. In Case 2, the mother of the boy was forced out of her matrimonial home because of her child's condition and the boy's relative including his stepfather were not interested in his welfare. The boy would have been reduced to a life of beggary like many others in o u r big cities but for the intervention of the "good samaritan ", the hospital ambulance driver. Apart from attitudes, the cultural beliefs also constitute a social barrier to rehabilitation. In most African societies, illness and physical defects are considered as a punishment or a curse for some wrongdoing? Such beliefs have often generated a feeling of guilt and unfavourable altitude towards the handicapped so that the child is often rejected, as shown in this case history. Case 3
R.I. was a 36-year-old-labourer in the warehouse of a tobacco company where he had been an employee for 3 years. He sustained a severe head injury in a road tralfic accident as a result o f which he remained unconscious for 3 months. He received intensive medical care in a hospital and was subsequently discharged after about 6 months. Soon after he resumed duty, he was found unconscious and had to be given emergency treatment at the factory clinic. He suffered from two further s~,milarattacks at elose intervals, and after thorough medical investigation a diagnosis of epilepsy was established and he was immediately started on treatment. His case was later reviewed by the company doctor who recommended that he should be transferred from the warehouse which involved working at heights to a less risky job and one that carried lower status, but with the assurance that his salary would remain the same. R.I. did not take kindly to this decision as he was convinced that his health problem, which he believed was due to an act ofwitchcraft inflicted on him by his former employer, could not be solved by a medical doctor. He expressed the hope, however, that his health would soon improve with the help of a local herbalist under whom he was receiving treatment and in whom he had great faith. Thus he failed to see the need for redeployment and continues to work under conditions which constitute a danger to his life. In Nigeria and indeed in most African societies, witchcraft is a reality, a belief which is very prevalent among literates and illiterates. 6 Disabilities, illnesses or any misfortune are attributed to acts of witchcraft and most people resort to native herbalists for solution to such problems. Thus proper medical treatment is often delayed. In Case 3, the man refused to take the advice of the company doctor because of his strong belief that his illness was not due to any clinical pathology but to the bad spell cast on him by his former employer. He therefore resorted to treatment by the native doctor and refused to be redeployed to a more suitable job. Finally, religion which is part of culture is a social problem in the rehabilitation of the handicapped. Most Nigerians are of Islamic faith. 7 This religion accepts beggary by the handicapped as a way of life and encourages the free giying of alms to such unfortunate people. Consequently, many who are only slightly handicapped and who could otherwise be gainfully employed parade the streets begging for alms. This paper has highlighted some o~f the social barriers to the rehabilitation of the handicapped in Nigerian society, and these include poverty, prejudice, cultural beliefs and practices. In any attempt to remove some of these social problems, it is suggested that the community be properly educated as to the true concept of health and disease, and it is hoped that such knowledge will lead to better understanding of the causes of various types o f handicaps and to improved management of such conditions.
Nigerian Handicapped ~Rehabilitation
85
Figure 1. Four blind beggars b y the side of a street in lbadan.
The family of the handicapped must not only be encouraged to accept the disability without necessarily raising in them false hope of absolute cure, but they must also be given guidance as well as moral and financial support. In the developed countries, handicapped persons are well catered for under the various social security schemes.~-1° In Nigeria, however, apart from the National Provident Fund Act o f 1961 which provides but a mere token compensation for injuries sustained at work, there is no other statutory provision for the handicapped. As our medical services continue to improve, so will the survival rate of children born with one form of handicap or the other. In addition, the recent rapid process of urbanization and industrialization is likely to expose more people to the risk of being maimed through accidents on the roads and in industries. These factors will inevitably increase the number of handicapped persons in our society. There is therefore an urgent need to establish a national social security scheme under which the government, the community and the voluntary organizations can work together to provide adequately for the many handicapped whose only means of livelihood is beggary (Fig. 1). Lastly, it is not enough to establish rehabilitation centres; it is equally important that they must be staffed with persons who have had training in the making and fitting o f appliances for the various types of handicap. Such measures will not only make expensive trips abroad unn~essary, but will also ensure that more handicapped persons are assisted to lead a more independent life if suitable appliances can be obtained locally and at relatively lower costs.
Acknowledgements The assist~mce of Mrs Omitowoju and Sister Catey of the Medical Social Worker's Department, U.C.H., Ibadan is gratefully acknowledged.
86
O. Oyemade and A. Olugbile References
I. Stolov, W. C. (1966). Rehabilitation and Medicine, S. Light (Ed.) Baltimore, Maryland: Waverley Press. 2. Gilles, H. (1964). Akufo - An Environmental Stud)" of a Nigerian Village Community. University of lbadan Press. 3. Ministry of Health Bulletin. (I 978). An Annual Statistical Btdletin of Ihe Epidemiological Unit. Oyo State of Nigeria. 4. Oyemade, A. (1975). Roy. Society oftteaith Journal 95. 282. 5, Amadi, V. (1980). Beliefs about causes of Disabilities in Nigeria: Implicationsfor the Management and Adjustment of the Handicapped Child in Home. Paper read at an International Conference on Cerebral Palsy on 16--19 January 1980. Universily of Ibadan, Nigeria. 6. Awolalu, Omosade, J. (1979). Jroruba Beliefs and Sacrificial Rites. Great Britain: Lowe and Brydone Press. 7. Nigeria Census (1963). In Population Census of Nigeria (1963). 8. Somers, H. M. & Somers, A. R. (1954). Workmen's Compensation; Prevention Insurance and Rehabilitation of Occupational Disability. New York: John Wiley and Sons. 9. Clark, D. W. & Machahon, B. (1967). t~reventive Medicine. Boston, London: Little Brown and Company. 10. Davies-Meredith, J.B. (1974). Preventive Medicine, Comnlun#y Health and Social Services. Billings and Sons Ltd. Press.