SUSTAINABILITY

Yes we can
Speech and language therapy is a fledgling concept in many African countries. On her return from the 3rd East African Speech and Language Therapy Conference in Kenya, Lois Cameron reflects on what the experience of these early pioneers can teach us about improving practice in the UK.

READ THIS IF YOU WANT TO CELEBRATE CONNECTIONS OLD AND NEW RAISE AWARENESS OF HIDDEN DISABILITIES TURN SHORTTERM INPUT TO LONG-TERM SOLUTIONS

Delegates at the 3rd East African Speech and Language Therapy Conference or seven years I lived in Nairobi as a child when, in 1967, my father was seconded from Glasgow medical school to help establish the medical school in Kenya. Up to that time Kenyan doctors had to be trained abroad. In 2009, the year of Homecoming Scotland, the great diasporas from around the world were encouraged to come and enjoy the country where they or their ancestors had been born. I made the trip the other way my Kenyan homecoming - to celebrate the connections of my childhood. I had read about the 2nd East African Speech and Language Therapy Conference at the end of 2008. I contacted the organisers to express my interest and they invited me to attend the 3rd event in 2009. This small pioneering group of therapists is trying to establish speech and language therapy within Kenya and address the needs of people with communication disability. Given my family heritage it felt a privilege to support them in any way, so I was delighted to volunteer to present at their conference. I ran two sessions; one an introduction to Talking Mats, the other a full days intermediate Talking Mats training for the speech and language therapists and support workers.

Kenya, with a population of 37 million, has a workforce that has never been more than eight speech and language therapists. This fluctuates as it is made up of residents, volunteers and partners of expatriate workers who are normally in the country on shortterm contracts. The speech and language therapists currently working in Kenya have had their initial training in a wide variety of countries: The Netherlands, USA, UK and India. The bulk of the therapists work is in Nairobi and is predominantly centred on three private hospitals, though a small proportion of work is done in outlying schools and clinics. Some of the therapists volunteer in the Kenya Institute of Special Education. Currently five therapists are based in Nairobi and two at the coast. These therapists work in immensely pressurised and isolated circumstances. It is impressive to observe the strong mutual support they give each other, and also their focus on continued professional development and ensuring they deliver a quality and up-to-date service. In addition to the seven Kenyan therapists, the conference was attended by VSO volunteers Fiona Bell and Isla Jones and student David Rochus Kyambadde, all from

the first Ugandan speech and language therapy course at Makerere University in Kampala. There were also three other UK speech and language therapy delegates and Karen Wylie, a speech and language therapist from Ghana. The conference was open to anyone with an interest in supporting the needs of those with communication impairment in East Africa and it was good to see the wide range of other professionals there: occupational therapists, rehabilitation assistants, nursery staff, special needs teachers, paediatrician, neurologist, dentist, parents and psychologists. It was heartening to experience the support from these professions and their commitment to improving services for people with communication impairment. A small professional group must particularly value the support of others and need their assistance in advocating their cause. As well as the sessions with a directly clinical focus, there was much discussion about the way forward for speech and language therapy in Kenya. This included developing a professional association and ensuring an increase in the number of therapists. There has been some discussion with the universities about establishing a course in Kenya, but the challenges are huge. Julie Marshall from Manchester Metropolitan University led a session on professional sustainability. She challenged the delegates to think about a model for delivering services to people with communication impairment that was a Kenyan solution not just one imported from other countries. She raised the issues of personal versus national sustainability. Individuals contributing on a short-term basis can try to come up with a local sustainable solution that will enable some carryover once they have left. National sustainability involves a vision for the country as a whole and needs a strategic plan in place to achieve it.

Challenging

The experience of the Ugandan course was interesting and gave much food for thought. VSO established the course in conjunction with Makerere University two years ago, with the first students enrolling in February 2008. The VSO volunteers co-ordinate the course, sourcing lecturers from other university

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departments and through specialists visiting from abroad. These are two really challenging VSO positions and the complexity of their task seems quite overwhelming to me. I really admire the courage and professionalism with which the VSO therapists are supporting the first cohort of 13 students, who are now in their second year. The short-term nature of VSO makes continuity and professional skill mix an extra. In addition, in a country where there are no long-term qualified speech and language therapists, professional support for these students when they qualify will be very limited if not non-existent. The question also remains whether there will be posts for them on qualifying. The first cohort of occupational therapists to graduate from Makerere had to wait 10 years before there were any government funded posts. This problem has been thought about and the course planners have tried to overcome it by writing a job structure and workforce plan at the same as the curriculum, but the jury is still out on whether this will be successful. There are 15 million children in Kenya. The lack of knowledge about the prevalence and impact of communication impairment is huge. In compiling a report for I CAN, Hartshorne (2006) reviewed the literature on prevalence in the UK and concluded that around 10 per cent of all children have longterm, persistent communication support needs, including the 6 per cent with primary speech and language impairment. As a nation Kenya puts a huge emphasis on the benefits of education, yet we know communication difficulties are a significant contributing factor to problems with learning, accessing the curriculum and developing to your full potential. Dr Sid Nesbitt, the paediatrician from Gertrudes Childrens Hospital in Nairobi, stressed the likelihood that early intervention prevents the more serious consequences of later learning disabilities. On the paediatric side alone the need for services is likely to be vast. A few people in Kenya in influential positions have some understanding of this but you can count them on less than one hand. The knowledge of physical disability is growing, but it is much more difficult to get hidden disabilities taken seriously. This lack of understanding is in a context of severe competition for funding against high profile health issues such as HIV and malaria. Karen Wylie gave an example from her time working in Zambia when therapists were able to piggyback on an extensive internationally funded HIV program. Once the children had started on a course of antiretroviral drugs, many developmental delays that were contributing to their poor health and wellbeing emerged. The workers were then able to get funding for a range of therapies. The cultural context also adds further levels of complexity. In Kenya there is a feeling that doctors should solve the problem, and that there should always be a medicine or an injection. There is therefore a lack of credence

given to other professions, particularly when people do not really know who they are, what their training is and above all what they can offer and do. In this context it can be hard to establish responsibility for self-management of a condition or for environmental management like changing the interaction patterns and language support between caregiver and child. General attitudes to disability in Kenya mean it is often difficult to access the children. Disability is seen as shameful and a curse, so the child is hidden away. The mothers are usually left on their own to bring up the child, as it is viewed as their fault, so economically they find themselves in a perilous situation. Karen Kibuchi is mother of a 7 year old with complex and multiple learning disabilities. She described to me how her eyes were opened when she went to study in Manchester, and saw her daughter could get the services and support that would help her realise her potential. Returning to Kenya has been hard as no school will accept her daughter. Karen, though, is a woman with determination. She realised she could not be the only woman in Kenya in this position, so she contacted her local churches and asked for women to get in touch with her if they had a child with a disability. Within two weeks she had 32 families and has now stopped asking because she has over 50 families coming to her for support. Through sheer hard work and dogged determination she has secured funding from General Motors to build a school and from the Ministry of Education to fund the teaching staff. She has yet to secure the running costs but I have no doubt she will. In the meantime she has founded the Initiative for Learning Disabilities Kenya and continues with the huge task of working with mothers to build their confidence, self-esteem and belief that their childs disability is not their fault.

Unintended barriers

So what do I take from my experience in Kenya that can be applied to my professional work back here in the United Kingdom? Julie Marshalls presentation reminded me that I am a member of a profession that is predominantly white, female, brought up in a Judeo-Christian setting and used to accessing western health care. A visit to a country where things are so different brings that into sharp focus and made me reflect on diversity with the people I work with in the UK. Here I am not just talking about cultural diversity but also value diversity. This is something we need to challenge ourselves on continually. At the present time in the NHS equality and diversity issues can become a bit of a tick box exercise, but I suspect if we dont get this right then we will be reducing our effectiveness. We will be putting unintended barriers in the way thus reducing our ability to listen and attend to the needs of clients and their families. The East African therapists have a richness in their training tradition drawn from across five different continents. It makes me wonder if we really make use of the experience of therapists who come from a different cultural, value or training background, and if we use their eyes to see things from their perspective. Is there a tendency to expect them to fit into our mainstream and not take fully the opportunity for learning that their background and experience offers? Another learning point is around sustainability. Whilst the pressures are different the issues are similar, particularly when services are under financial constraints. There needs to be as much planning at the start of projects, new initiatives or redesigns as to how the input will be sustained long-term. There also needs to be active consideration of any unintended

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Servox appeal

Talking Mats sessions at the Conference consequences of input. This is important for personal as well as service initiatives. Finally, the conference made me reaffirm that the power of working with others - be they speech and language therapists or other members of the multidisciplinary team -enables people to achieve great things. Networking and building alliances with other professionals and patient groups is a key component of change. In leadership terms we need to continue to develop our skills and capacity to do this. strategy to achieve the vision, and designed to be fit for purpose. There was acknowledgement that considerable investment and support will be needed to carry out training, and the existing number of therapists cannot commit to this. I was left impressed with a group of therapists who are working under huge workload pressures but supporting each other to ensure a work life balance and to keep professional standards high. Many of the issues faced by the East African Speech and Language Therapists would have been those facing speech and language therapists in the UK 30 years ago. After all, it is not so long since we locked people with disabilities in asylums and, while I do not know much about the start of our Royal College, I suspect we are indebted to some committed individuals who deliberated long and hard about the best way forward in terms of developing a professional association. I am sure in the future people with communication impairment in Kenya will be grateful to the pioneering work of the therapists currently working there. I was privileged to be able SLTP spend time with them. Lois Cameron is Talking Mats Development Manager at the Talking Mats Research and Development Centre, University of Stirling, tel. 01786 458105, e-mail l.f.cameron@stir.ac.uk.

Speech and language therapist Emma Shah, who has worked in Nairobi for 10 years, would welcome donations of Servoxes and Servox batteries in working order. As reported in our Winter 09 issue (p.3), trache-oesophageal puncture operations are not done in Kenya, so clients get a traditional laryngectomy with little surgical followup. Servoxes are in demand for those who cannot achieve oesophageal voice. Emma says donors should also factor in the costs of couriering the equipment to the airport in Nairobi where Emma will collect them. If you can help, contact shah.emma@gmail.com. The Kenya Association of Laryngectomees is active in running monthly meetings and residential workshops for people in outlying areas, but the organisation is dependent on donations to meet its running costs. Its organising secretary Bishop Duncan Mbogo Wanjigi has developed a website (www.laryskenya.org) which includes a Paypal facility.

Reference

Hartshorne, M. (2006) The Cost to the Nation of Childrens Poor Communication. I CANTalk Series Issue 3. London: I CAN.

Resources

Pioneering spirit

There is much pride in Kenya about Barack Obamas success, and his slogan Yes we can is an appropriate phrase. Karen Kibuchis story reflects that attitude and it is also in the pioneering spirit and professionalism of the speech and language therapists. By the end of the conference they agreed to set up a group that will be open to all who wish to develop services for people with communication impairment in East Africa. While this might evolve into a more specific professional association at a later stage, there are not sufficient numbers to sustain such an association just now. The therapists involved are using the information gathered and worked on at the conference to develop a vision for how services for people with communication impairment should be delivered in a way that is appropriate to Kenya. They recognise that raising awareness and creating a sense of ownership of the problems faced by people with communication impairment is critical, and that the preliminary work needed to be done whilst fostering and developing any key and influential relationships. They feel that this piece of work needs to be in place before the establishment of any training course; the training course can then be part of the overall

Caroline Bowens information page on SpeechLanguage Pathology in East Africa - www. speech-language-therapy.com/africa-e.html ICAN - www.ican.org.uk/Resources/ICTalk%202.aspx Initiative for Learning Disabilities Kenya www.ildkenya.org/ Kenya Institute of Special Education - www. kise.co.ke/ Makerere University College of Health Sciences - http://med.mak.ac.ug/ Talking Mats www.talkingmats.com VSO - www.vso.org.uk/volunteer/

Acknowledgements

I would like to thank all the therapists I met, in particular Laura Dykes and Emma Shah for the huge amount of work they did to organise the conference. I would also like to thank Bette Locke and the AHP travel scholarship Forth Valley for contributing towards my travel costs and Mary Turnbull, Head of the Speech and Language Therapy service for her continued support.

REFLECTIONS DO I RECOGNISE THE BENEFITS TO MYSELF AND TO OTHERS OF VOLUNTEERING? DO I ACTIVELY CONSIDER THE UNINTENDED CONSEQUENCE OF AN ACTION OR DECISION? DO I EXAMINE THE IMPACT OF DIVERSITY OF VALUES ON MY PRACTICE?
Do you wish to comment on the difference this article has made to you? See the information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

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