Abstract
In West Africa, as in Majority World countries, people with a communication disability are generally cut-off from the normal development process. A long-term involvement of two partners (Orthophonistes du Monde and Handicap International) allowed the implementation in 2003 of the first speech-language pathology qualifying course in West Africa, within the Ecole Nationale des Auxiliaires Medicaux (ENAM, National School for Medical Auxiliaries) in Lome, Togo. It is a 3-year basic training (after the baccalaureate) in the only academic training centre for medical assistants in Togo. This department has a regional purpose and aims at training French-speaking African students. French speech-language pathology lecturers had to adapt their courses to the local realities they discovered in Togo. It was important to introduce and develop knowledge and skills in the students’ system of reference. African speech-language pathologists have to face many challenges: creating an African speech and language therapy, introducing language disorders and their possible cure by means other than traditional therapies, and adapting all the evaluation tests and tools for speech-language pathology to each country, each culture, and each language. Creating an African speech-language pathology profession (according to its own standards) with a real influence in West Africa opens great opportunities for schooling and social and occupational integration of people with communication disabilities.
Introduction
Wylie, McAllister, Davidson, and Marshall (Citation2013) suggest that the speech-language pathology profession must debate what it is that our profession wants for people with communication disabilities (PWCD): more speech-language pathologists or more speech-language pathology services—perhaps delivered by others. Where should our profession focus its energy for change: at the level of primary, secondary, or tertiary intervention?
Following related questioning, some humanitarian organizations such as Orthophonistes du Monde and Handicap International started to look into it and created, among other things, a speech-language pathology basic training program in West Africa, with related courses on three levels: prevention, evaluation, and treatment of communication disorders. In West Africa, as in many other parts of the world, people with disabilities are largely excluded from the development process and have limited opportunities to get involved in consultation and in public decision-making. The status of people with disabilities in Togo is giving cause for concern, in spite of a significant breakthrough which occurred in 2010 with the ratification by the Togolese parliament of the International Convention on the Rights of Persons with Disabilities (United Nations, Citation2006).
Social representations of people born with an impairment result from cultural perceptions of the society they belong to and in which they have multifaceted relationships (N’Daye, Citation2000). In West Africa, although people with disabilities are rarely excluded from their families or communities, they are frequently considered as unproductive and with no future. Distinctions made between disabilities are significant. People with intellectual or physical impairments are more often rejected by others, while those with a communication disability are generally excluded from the development process because their distorted communication impedes their social inclusion. African societies are societies of oral communication, in which culture and knowledge are passed down through oral tradition. Social exchanges are based on speaking exchanges. Telling one's name to a stranger is like giving a present and initiating a real exchange (Manteau, Citation2001). Deafness and mobility impairments have direct consequences on oral language learning and, thus, create a real disability. According to the World Health Organization (Citation2012), more than 275 million people are deaf or hearing impaired, 80% of whom live in countries with low or medium- income. Malaria, mishandled medicine, noise pollution, and serious accidents are the main causes for deafness in many countries. Sometimes considered as secondary care, speech-language pathology services improve access to education and social integration of people with speaking and other communication disorders.
The sociolinguistic situation in Togo
Togo is a small country in West Africa, extending over 600 kilometres from north to south. It is a multilingual and multi-cultural society, with a population estimated at ˜ 5 million people, divided across a mosaic of races. There are in fact 48 ethnic groups in the country, none of which is in the majority. Corresponding to this large number of ethnic groups, there is an equally large number of languages. None of these has had any real success in establishing itself across the whole country, but the Ewe in the south and the Kabiye in the north have the largest numbers of speakers. The ethnic groups of the Kwa group live in the south of the country, particularly the Ewe (22%) and the Ouatchi (8.3%). In the less densely populated central and northern regions, there are the members of the Gur group of ethnic types, particularly the Kabiye (13%), and in the most northerly areas there are the Temberma groups, who are among the most ancient populations of Togo (Cornevin, Citation1988).
In terms of the numbers of speakers, the most important languages are Ewe, spoken by 20% of the population, and Kabiye, spoken by 16% of the population, as well as Watchi (8.3%), Tem (4.6%), Moba (4.3%), Naoudem (3.3%), and Lama (2.6%). Although each region of Togo has one or two dominant languages, it is essential to note the great ethnic diversity in every city. It is rare to find within a given geographical area that a significant proportion of the population is monolingual or monocultural. As a consequence, Togolese children are born and grow up in a very diverse linguistic environment.
The education system in Togo
The realities of education in Africa are also distinctive, and for this reason we describe the system briefly below. Before they start school, children speak their native language, and possibly one or two other languages, depending on the groups their parents and grandparents belong to. This is, therefore, a diglossic situation, where the languages spoken are indicators of the ethnicities and cultures of the speakers. The French language, which remains the main language of education in several African countries, occurs as a foreign language for the majority of children, as more than 60% of school children come from rural environments where their parents are not in contact with French. Nurseries and primary schools (in the majority of cases) are very often the only places where a child comes into contact with French as a second or third language. On the other hand, diglossia is found everywhere in urban areas, and here it is only in rare circumstances that people speak a pure form of either French or a local language. Lexical borrowings in both directions are used all the time (Gbeto, Citation2006).
In the school environment, the pupil's first language is officially not present in the classroom. The failure of schools to take account of the language experience of the children is harmful from several points of view. Banning the use of the first language devalues it as the foundation of the cognitive and social identity of the pupils, and runs the risk of leading to a subtractive bilingualism, where children are incapable of maintaining a conversation in a language without borrowing lexical items from another language (this is the case particularly in urban areas). Children often fail to understand classroom activities; although they have at their disposal significant discursive capacities in their first language, they are reduced to speaking for 1 or 2 years in laconic fragments in reply to the teacher's questions. Their knowledge of the world constructed within their first language is not taken into account in subjects which have to do with the environment and their experience of the world, since these subjects are presented in a formal way, without any connection with real life. The knowledge transmitted by the endogenous culture is not promoted by the school, which can lead to a divided personality, and the breakdown in the onward transmission of the culture. This threat which schools pose to the survival of cultures leads many parents, particularly in rural areas, to dread sending their children to school, because they fear that their children will lose their native culture as a result.
In this diglossic context, the system of monolingual education through the medium of French seems unlikely to be able to make African countries truly francophone. In fact, during the first 2 years at school, the progress of pupils remains very slow, and this is a result of the persistent difficulties of communication and especially of comprehension which prevail between teacher and pupils. This teaching system is not without its consequences. It leads to large numbers of children failing in school.
Orthophonistes du Monde (OdM)
The association Orthophonistes du Monde (Speech and Language Pathologists of the World) was established in December 1992 by the members of the management board of the FNO (Federation Nationale des Orthophonistes, French National Federation of Speech and Language Pathologists). This was in response to repeated requests for help received by the FNO from countries where the speech-language pathology profession did not exist. This included requests for training courses, equipment, and advice, submitted either by professionals or by parents and family members. Because these requests were arriving increasingly often, the FNO decided to set up an independent association, supported by the profession, to respond to these needs. The Statutes of the OdM were written with the intention of respecting local cultures as much as possible, and of creating a real partnership with the associations which asked for help, so that they would become increasingly autonomous.
Consequently, OdM included among its objectives the following statements:
• “to facilitate and carry out humanitarian projects, involving collaboration, technical assistance, field research abroad, and missions involving scientific exchange and training in subjects related to speech and language pathology, with countries outside the EU which ask for this type of assistance”.
• “to send out to partner countries speech-language pathologists and relevant technical staff, where they are needed to fulfil the objectives of these projects”.
The two primary aspects of OdM's interventions are the setting up of initial professional training courses, and the provision of other locally-based training. The first projects took place in Lebanon, Vietnam, the Philippines, Europe (outside the EU), and Togo. More recently, OdM has been active on a regular basis in Africa, including the Maghreb, and is starting again to run projects in Asia, including in India and Bangladesh.
Since its establishment, OdM has contributed to the establishment of two initial training centres (at professional diploma level) in Lebanon and Togo, which have led to the creation of a local speech-language pathology profession which is, therefore, completely adapted to the needs of the countries and indeed the regions involved. For example, the Speech and Language Pathology School at Lomé in Togo trains speech-language pathology professionals for the whole of francophone West Africa. OdM works in partnership with other humanitarian associations which share a common ethos, including for example Handicap International, Ortho-Benin, Médécins du Monde (Doctors of the World), and Kinés du Monde (Physiotherapists of the World).
Among the projects initiated by OdM, there are an increasing number of training missions aimed to teaching professionals about communication disability. The mid-term or long-term purpose of OdM is to “help developing speech and language pathology in some countries by implementing initial and certificate courses and by creating a formal status for this profession” (Marcotte & Kremer, Citation2003, p. 20). This purpose relates to Recommendation 5 of the World Report on Disability in terms of appropriate training in the field of rehabilitation.
Handicap International (HI)
The non-government organization Handicap International has been active in Togo since 1997, and has chosen to focus its work on the training of rehabilitation professionals. The first project was entitled “Capacity Building in Three Departments of ENAM” and focused on physiotherapy, ortho-prosthetics, and speech-language pathology. It was financed jointly by the Luxemburg Ministry of Foreign Affairs and the European Union (2003–2006), implemented by HI Togo, and was completed at the end of 2006. This project also received support from other partners, and was successful in bringing about a significant improvement in the training of rehabilitation professionals in Togo. A partnership between OdM and HI was initiated in 1999. In October 2000, this partnership led to the creation of a position of speech-language pathology project leader. This long-term position in Togo provided support to residential homes for people with special needs and associated organizations supporting people with communication disorders. This position was filled by an expatriate French speech-language pathologist. A 2-year awareness campaign was implemented to develop speech-language pathology services (hitherto absent from the country) for people with various disabilities.
An initial continuing education program, not a qualifying course but meant for educators, teachers, and nurses, was implemented in early 2003. Eight French speech-language pathologists led this modular training about communication disorders. The main objective was to allow professionals (nurses, teachers, and educators) in the areas of health and education to give better care to people with communication disorders.
The long-term involvement of the two partners was conducive to the implementation of another large-scale project in 2003: the first speech and language pathology qualifying course in West Africa, within the Ecole Nationale des Auxiliaires Medicaux (ENAM, National School for Medical Auxiliaries) in Lome, Togo. This level of commitment had not yet been present in other countries in West Africa.
Ecole Nationale d’Auxiliaires Médicaux, National School for Medical Auxiliaries (ENAM)
ENAM operates under the joint supervision of the Togolese Ministry of Health and the Ministry of Technical Education and Professional Training. It is led by a Director appointed by the government, on the basis of a nomination by the two ministers involved. The director is assisted by a deputy, who is also the director of studies, and is appointed by the Minister of Health. The Heads of Departments (the lead trainers) are appointed by ministerial directive, following a nomination by the Director of the School. Since its creation in 1945, ENAM is the only approved and regulated academic training centre for paramedical staff in Togo, and the only training centre for second-level ortho-prosthetic technicians and speech-language pathologists in the whole of West and Central Africa.
At present, ENAM has seven departments, including registered nurses, laboratory technicians, hygiene assistants, massage therapists and physiotherapists, ortho-prosthetic technicians, speech-language pathologists, and sanitation auxiliaries. The length of training has increased steadily. In 1945 it was fixed at 1 year, then in 1950 it was raised to 2 years. Since 1975 it has been 3 years for all the departments. Since 2001, candidates sitting the competitive entrance examination for ENAM's courses have been required to have passed the baccalaureate (qualification taken at the end of secondary education). The teaching staff in ENAM are either permanent (these trainers are recruited through a competitive process) or temporary staff. The teaching program is organized in a semester structure, with two assessments during the year.
For information, here are the numbers of students admitted to ENAM within the various courses: registered nurses (100), laboratory technicians (20), hygiene assistants (20), massage therapists and physiotherapists (20), ortho-prosthetic technicians (10 every 3 years), speech-language pathologists (20 every 3 years), and sanitation auxiliaries (100).
It is also important to emphasize the international role of ENAM. In the case of initial training in massage therapy and physiotherapy, ortho-prosthetics and speech-language pathology, students come to ENAM from several countries in West Africa (Cape Verde, Senegal, Burkina Faso, Ivory Coast, Benin) and Central Africa (Chad, Burundi, Cameroon). The impact of a high quality training course is therefore felt both in Togo and elsewhere in the region, meaning that treatment can be provided to disabled people both in Togo and beyond. Togolese speech-language pathology students pay a low level of tuition fees. In the case of the non-Togolese students, tuition fees are charged at a higher level, which ensures the financial stability of the speech-language pathology department, and enables the department to pay for the visits of French-speaking speech-language pathology educators as guest lecturers. Students from outside Togo have the benefit of bursaries from their home countries to enable them to study in Togo for 3 years. These bursaries are awarded by the authorities in those countries or by NGOs working in the region. Ten Togolese students graduated in July 2006 with a speech and language therapy degree. The second class of 20 students (from Togo, Benin, Burkina Faso, Congo, and Cameroun) graduated in 2010. The third class has 33 students and will graduate in July 2013.
The specific context of the speech-language pathology training course
Theoretical training is organized in 16 modules. Practical placements take place in hospital settings (Tokoin University Hospital and Campus University Hospital) and also outside hospitals (Ephphatha School for Deaf Children, L’Envol School for Disabled Children) and are closely linked to the content of the theoretical courses. The first students benefitted from a year of theoretical courses taught by Togolese professionals and academics (psychologists, medical doctors, and linguists). Because there were no qualified speech-language pathologists in Togo, French specialized teachers had to volunteer through OdM and HI to teach pathology, assessment, and therapy techniques in the second and third years of the course. The training is based on a combination of approaches intended to promote integrated learning. Practical placements enable students to develop practical skills, and the School provides the theoretical training. A range of teaching methods is used, including lectures, practical workshops, supervised self-study, seminar groups, reflective analysis of practical work, observation sessions, and practical clinical placements.
The teaching missions led to very deep exchanges between the students, who got to discover the reality of their future professional practice, and the teachers, who had to adapt their courses to the local realities they discovered in Togo (Develay, Citation1995). It was important to introduce and develop knowledge and skills in the students’ frame of reference. “Training only works if it allows the teachers to wonder about their goals and the way they operate. Humanitarian help can only be considered as a mutual transformation” (Gagnayre & d’Ivernois, Citation1994). In addition, maybe more than other humanitarian missions because they work with communication and language, the speech-language pathology missions require knowledge and know-how, the ability to reduce them, and breaking and rebuilding knowledge according to the human framework: cultural, linguistic, socio-economical, and ecological (Manteau & Topouzkhanian, Citation2006).
The French speech-langauge pathologists had a dual mission with the second class: teaching the students but also teaching the new Togolese speech-language pathologists hired by ENAM in 2006 about direct and indirect pedagogy. The basic training had to be made sustainable, so some Togolese speech-language pathologists were trained to become lecturers and were thus enabled to keep the department going (Legrand-Salomon, Citation1996). This activity has been enabled by an official partnership between ENAM in Lome and the Institut des Sciences et Techniques de la Réadaptation de Lyon (ISTR, Université Lyon 1 – Sciences and Techniques of Rehabilitation Institute of Lyon) since 2005.
From 2007 onwards, Handicap International began a process of gradual withdrawal, by putting in place a number of activities intended to safeguard the long-term impact of the training which had been offered to ENAM. As part of this process, and thanks to the financial support of the Service for Co-operation and Cultural Action of the French Embassy in Togo, the partners were able in 2007 to set up a workshop for reflection and forward planning of ENAM's activities for 2008, 2009, and 2010, to support the School in becoming more autonomous. The workshop brought together the external partners who had contributed to the growing self-confidence of ENAM over the previous years.
The speech-langauge pathology department currently operates autonomously, with four qualified Togolese trainers, who all have partnerships with French training establishments. They have regular access to high-quality continuous professional development opportunities either in Africa or in France.
Speech-language pathology services in Togo
To make the profession of speech-language pathology (also known as speech and language therapy) recognized in Togo, positions for civil servant speech-language pathologists had to be created. Today, 19 speech-language pathologists work in Togo in public health structures (e.g., teaching hospitals, the National Center of Orthopedic Bracing), or in specialized schools (e.g., for children with hearing impairment or intellectual disability). Most speech-language pathologists also have a private practice.
Together with the introduction of this new health profession, speech-language pathology was promoted throughout these past 11 years to make it known to local authorities, professionals in the areas of health and education, and the Togolese people. Promotion activities in communities have included awareness campaigns in schools and healthcare services, and the media (newspapers, radio, and TV). Awareness tools such as posters or leaflets have been created by speech-language pathologists. Lobbying commenced in 2005 to make known the new department of ENAM and improve its visibility, as well as to ensure the recruitment of foreign students for the years to come and to look for a funding system. Speech-language pathology services are paid for by patients or their families, within hospitals or in private speech-language pathology clinics. However, some institutions and associations provide speech- language pathology services without charge (for example, the Envol Centre, and the association Development Action Health for All). The level of fees charged within private practice are fixed by speech-language pathologists themselves, taking account of the incomes of families. There is so far no government regulation of the level of fees charged by speech-language pathologists in private practice.
Students and speech-language pathologists know they need to get involved with preventive actions and detection so that the patients get to their practice. They have to face many challenges: creating an African speech-language pathology, introducing language disorders and their possible cure by other means than traditional therapies and beliefs (see later), and adapting to each country, each culture, and each language all the evaluation tests and tools for speech-language pathology (Abalo & Topouzkhanian, Citation2007; Ate, Citation2006). Indeed most of the speech-language pathology tests currently used in West Africa were imported from Europe so made according to a culture and specific standards, not adaptable to the African reality (inter-cultural and inter-linguistic differences with regard to pictures, vocabulary, and language learning standards, etc.). The African speech-language pathologists also need to carry on advocating to politicians and service managers.
In relation to the transmission of medical knowledge, health education may frequently clash with beliefs, behaviours, or values conveyed by popular wisdom (e.g., cutting the lingual frenulum when a child starts talking late; inserting hot stones under the tongues of children with a stammer). Education may be perceived as incursions from an unfamiliar medical system (Masse, Citation1995). Popular wisdom needs to be considered by health professionals, including SPLs, for them to be able to strategically and culturally adapt their direct and indirect practices regarding prevention, detection, family guidance, and aid for the helper, to the context (cf. Empowerment Theory, Talbot, Citation2003).
Professional development and growth
The involvement of OdM did not stop when the first students graduated. It seemed important to support young professionals starting their profession in countries or regions where they are pioneering. This support occurs through e-mail and includes professional advice or provision of documentation or materials. OdM also co-ordinates missions for continuing education to meet the needs for further training. The OdM teachers also meet their African colleagues in their practice when they have the opportunity to do so.
The nationally recognized department of speech-language pathology training at ENAM in Lomé also has a role in the provision of post-qualification training to professional speech-language pathologists. In connection with this, in April 2011 the department organized a training workshop, jointly with OdM and with financial support from Handicap International, which was intended to develop and adapt assessments of language and communication disorders which could be used by all speech-language pathologists in Togo. An example was the creation of an instrument to assess language skills in children up to 6 years of age, in three languages (French, Kabyè, and Mina).
Student speech-language pathologists are faced with numerous challenges in this very particular linguistic situation, and with recurrent questions about the acquisition and mastery of the languages involved; for example:
• In which language(s) should one assess a bilingual or multilingual patient?
• How can one provide therapy to a patient with whom one does not share a common language?
• Is a complete mastery of the patient's language necessary to offer therapy?
• How should we conceptualize the presence of the interpreter as a third person within a therapeutic situation?
• Is it sufficient to rely on an interpreter for the translation of the tests used in a speech- language pathology assessment? How should we proceed in the case of lexical differences between the two languages?
Most of the time we can only support the teams, as they reflect on how the languages of communication and education could be used and presented to children. Working in bilingual and multilingual settings requires us to involve families in these educational projects; educationalists who themselves originate from these various ethnic groups can of course also help with this development.
The number of speech-language pathologists practicing in West Africa steadily increases and OdM tries to encourage exchanges between them. Forty have been identified to date (Gascoin, Citation2012), and of these 23 were trained by ENAM. Out of the 15 Togolese speech-language pathologists trained at ENAM, four are currently practicing abroad in Gabon, Ivory Coast, and Benin (Gascoin, Citation2012).
Last November, a co-ordination group of speech-language pathologists practicing in West Africa was established during a professional meeting in Ouagadougou. Research into language impairments is being carried out regarding the impact of environmental factors. Partnerships between universities are being established to improve skills in rehabilitation, as recommended by the World Report on Disability (recommendation 9).
Table I. French-speaking speech-language pathology (SLP) students and graduates in West Africa in 2012.
Conclusion
Speech, language, and culture are inseparably linked together. While it has its roots in the relations of self and others, the language faculty is a property of the individual. It gives each one of us our individual character, and develops within the interdependence of thought and language. Culture, on the other hand, forges our vision of the world, our beliefs, our ways of communicating, and the different styles of interpersonal relationships which occur in different communities. In a speech-language pathology clinic, overlapping perspectives between the various disciplines are essential. Creating an African speech-language pathology profession (according to its own standards) with a real influence in West Africa opens great opportunities for the future in favour of schooling and social and occupational integration of people with communication disabilities.
Acknowledgements
Many thanks to Mr Joe Reynolds and Mrs Anne-Laure Krikorian for translating this article.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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