Promoting change through political consciousness: A South African speech-language pathology response to the World Report on Disability

Abstract

In the context of the World Report on Disability, question how speech-language pathologists (SLPs) change practices to benefit under-served people with communication disability. This commentary provides a South African response premised on Political Consciousness. In South Africa, a grossly unequal society, the under-served population is not only those with communication disability but also include those who are at a communication disadvantage due to disabling conditions. As a consequence of the combined effects of a severe shortage of SLPs as well as maldistribution in service provision, the under-served are mainly poor Black South Africans who are the majority population. Political Consciousness allows one to examine how selected forces at the macro-level, meso-level, and micro-level may enable or limit services to the under-served majority. At a macro-level, this study appraises policies and actions advancing and impeding service delivery. At the meso-level it is argued that hegemonic professional knowledge is limiting and an equity-driven population-based approach is advocated. At a micro-level, the Relationship of Labouring Affinities is offered as a conceptual tool for critical engagement. In conclusion, it is suggested that the speech-language pathology profession must collectively become political actors at all levels to effect change.

Keywords::

• World Report on Disability
• political consciousness
• equity
• population
• speech-language pathology
• South Africa
• disability

Confirming and contextualizing the increasing prevalence of communication disability and at-risk populations

Similar to the international context, there is no data confirming the prevalence of communication disability in South Africa. The disability prevalence for South Africans over the age of 5 years ranges from 6–12% across provinces (Statistics South Africa, 2011). In South Africa the quadruple burden of disease creates a major context for disability. The quadruple disease burden refers to:

• maternal, newborn, and child health illnesses,

• human immunodeficiency virus (HIV) and tuberculosis (TB),

• chronic, non-communicable disease (cancers, high blood pressure, diabetes), and

• the effect of violence and injury in the population.

These conditions, all of which are associated with disorders of communication and/or swallowing, affect the majority of Black South Africans, particularly women and children, who continue to live in poverty (Sanders & Chopra, 2006), curtailing their opportunities for development.

In addition to diseases impacting on prevalence of communication disability, we are equally concerned about those who are not developing optimal communication in the context of structural (race, gender, class) inequalities. Structural inequalities resulting from patterns of power and discrimination in society block peoples’ advancement (Graaff, 2001). One would expect that South Africa, as a middle-income country with political freedom, has become a more equal society. This is not the case. Poverty and inequality are prevalent and the country remains one of three most unequal countries in the world (Bhorat & Kanbur, 2006, p. 1–17). The combined effects of the burden of disease and structural inequalities affect poor, and mainly Black South Africans (who make up 75% of the population), resulting in a large-scale pervasive problem.

The impact of poverty and inequality in South Africa is visible in all domains and particularly in poor school performance. For example, the schools’ Annual National Assessments indicated that between 12–31% of learners from grades 2–7 (usually 7–14-years-old), mainly from poor communities, did not meet adequate grade level performance in literacy and mathematics (Department of Basic Education, 2011). These learners may not have communication impairments, but are at a disadvantage due to a range of social and economic conditions (unemployment and poverty, drugs, violence, illness, teenage pregnancies) including poor quality education. As a consequence of these systemic influences, learners do not develop adequate communication and literacy skills restricting their further education and employment opportunities. These learners with poor literacy development, as well as those with communication impairments, have little or no speech- language pathology support in the public sector (Kathard, Ramma, Pascoe, Jordaan, Moonsamy, Wium, et al., 2011). In South Africa, we reiterate the case for a more inclusive view of the under-served population which extends beyond those with disability to include those who experience social disadvantage. Against this backdrop we ask: How have under-served peoples’ interests been addressed in South Africa?

A comprehensive view of the distribution of SLPs in South Africa across public and private sectors is not available. The total number of SLPs registered with the Health Professions Council of South Africa (March 2012) is 2011 and the population is estimated at 51.7 million people (Statistics South Africa, 2012). As a best case scenario, the SLP to population ratio may be estimated at 1:25,000. In reality, however, the situation is worse, as many SLPs registered with the HPCSA are abroad, while others are inactive. The SLP-to-population ratio in US, UK, Canada, and Australia ranges between 1:2500 and1:4700 (Wylie, McAllister, Davidson, & Marshall, 2013), which, when compared with the estimated 1:25,000 ratio, indicates (relative) serious under- resourcing in South Africa. However, the maldistribution of SLPs is also concerning.

The South African Speech-Language Hearing Association (SASLHA) had a membership of 1077 members in 2011. Our preliminary analysis of their data base (C. Emmerick, personal communication, 12 March 2011) indicates that most practitioners are:

• in private practice (67%),

• in urban areas, and

• mother tongue English/and or Afrikaans language speakers (95%) (vs only 5% Black African language speakers).

Compared to previous analyses of speech-language services in apartheid South Africa (Pillay, Kathard, & Samuel, 1997), the current state is similar in that the under-served populations still are the majority of Black South Africans. So, how may the communication needs and interests of the under-served majority be addressed?

We advocate Political Consciousness (Miller, 2002) as a lens to examine how forces and actions at a macro-level, meso-level, and micro-level by SLPs may advance or limit equitable service delivery to under-served populations. Political Consciousness involves using social justice as our value base for constructing, caring, and acting in all contexts. To do this SLPs must be critical of and act on social, cultural, political, economic, and even personal forces, systems, and structures which create and perpetuate inequality. Here, we argue that speech-language pathology as a profession must harness new forms of transformative power that makes the creation of an egalitarian and caring society possible. As such, Political Consciousness implies that we need to be tolerant and accepting of being disrupted in order to challenge and change historical, taken-for granted practices (Kronenberg & Pollard, 2005).

Meta-level policies and actions enabling/restricting change

In post-apartheid South Africa (1994–) pro-equity, population-based policies exist across public service sectors to reduce inequality. The health sector changed radically by adopting Primary Health Care as an approach with the District Health System as a vehicle for service delivery (Department of Health, 1997). As a general strategy to address human resources provision in health in under-served areas, compulsory community service (CCS) for 1 year (Department of Health, 1997) became mandatory for all new health professional graduates. This political strategy driving equitable service provision with under-served communities has been in place for SLPs since 2003. Each year ˜ 140 SLPs are placed in Community Service posts. Over time, service delivery issues and challenges have surfaced. Two key issues, relevant to the global community, are those of language-matching and engaging with poverty.

The experiences and perceptions of community service SLPs (Khan, Knight, & Esterhuizen, 2009; Penn, Mupawose, & Stein, 2009) highlighted their challenges with linguistic and cultural barriers. In a country with 11 official languages, a dearth of Black African SLPs, and a history of English/Afrikaans dominant services, it was clear that language- matching between SLPs and communities they served would be impossible. Community service SLPs experiences challenged the feasibility of language-matching (between SLP and client) in a multilingual context. On-site language learning and working with interpreters were found to be useful service development strategies, especially in under-served communities. While language-matching and access to trained translators/interpreters, albeit a challenge, is argued for and is often possible in resource-rich, multilingual countries such as the US and Australia, for a large part of the world, and in contexts such as South Africa, it is not feasible. Based on his experiences of practice in South Africa and with migrant workers, Pillay (2013) suggested that SLPs aspire towards a practice which is trans-linguistic and self-sufficient; that is, they must develop a set of clinical competencies to manage the reality of cultural and linguistic diversity.

The community service experience in South Africa also highlighted that SLPs in poor, rural areas are often overwhelmed by the (fundamental) challenge of poverty. Therefore, as part of training and professional development, SLPs must engage with complex issues of poverty as part of service provision. As a profession, we must also demonstrate our relevance and participation in nation-building by accumulating an evidence-base which shows how our interventions contribute to the bigger project of poverty alleviation and reducing inequalities.

In addition to CCS, we have further policy-driven opportunities for improving services in the public sector through initiatives such as Re-engineering of Primary Health Care (Naledi, Barron, & Schneider, 2011), National Health Insurance (NHI) (Department of Health, 2011) and Action Plan 2014 for Basic Education (Department of Education, 2011). In our view, the NHI can be the next major pro-equity opportunity for SLPs, because it will encourage private practitioners to offer services in the public sector through contracting with the Department of Health. This initiative has potential for addressing the current maldistribution of services.

We agree with Wylie et al. (2013) that the World Report on Disability can be a catalyst for change at an international level. However, there are three ways in which it can also limit (hinder) change. First, while promoting partnerships with people with disabilities, the World Report on Disability authors do not consider how traditional power struggles will be negotiated. People with disabilities (PWD) deliberately used a human rights and social model to advance their interests, resisting incursion and domination by the rehabilitation professions. We must be vigilant that, in our attempts to advocate for people with disabilities, professionals do not usurp the power of local constituencies, creating a new form of dominance via so-called advocacy and empowerment.

Second, the International Classification of Functioning, Disability, and Health (ICF) (World Health Organization, 2001) is promoted as a framework in the World Report on Disability for guiding the practice of rehabilitation professions. We argue that the ICF on its own is potentially restrictive because it lacks political clout. Helander (2003) explains that the ICF does not consider the disabling contexts of poverty, abuse, exploitation, and oppression which are the lived realities of people with disabilities. We suggest that the ICF should be combined with social and human rights models of disability while simultaneously developing professional practice frameworks.

Third, the World Report on Disability uses a narrow definition of rehabilitation described as “a set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments” (World Health Organization and The World Bank, 2011, p. 96). The report explicitly states that “barrier removal initiatives at societal level” is not within the scope of rehabilitation. This stance goes against therapist-driven public interventions which will effect social change to benefit under-served populations (e.g., advocating for FM loop systems in public spaces).

Meso-level transformations: Profession as organizations

While external forces are driving change, it is at the level of the profession that we must create spaces for fundamental transformation to respond to under-served populations. This challenge applies to current, dominant models in the Minority World as well those needed for the Majority World. It requires that professionals—in any context—must effectively change the “truth regimes” (Brante, 2010, p. 843) upon which our profession has been grounded. What is meant by this?

Professions have historically-defined, hegemonic foundational practices (Brante, 2010). For speech-language pathology, our foundational (and consensual) knowledge base has been referenced to the medical model—the limitations of which are well-documented. Even with the positive influences of the biopsychosocial model our emphasis continues to be on the individual, thereby limiting our fuller understanding of populations. Our knowledge base is characterized by theoretical imperialism (Hammel, 2011). This means that SLP knowledge was created by powerful, Western imperial cultures that privileged their own perspectives about health and rehabilitation. By virtue of ethnocentrism (i.e., a strong belief that their culture was superior to others), the Western knowledge base has been promoted as universal, even though it is partial and cultural in itself. In the colonized Majority world, these universal truths have been imposed in several contexts where lived realities of communication and its disorders are/were vastly different. Hence, traditional individualized speech-language pathology practices in South Africa uneasily exist with “Ubuntu”, an African worldview in which “a person becomes a person through other persons” (Swanson, 2007, p. 55). Ubuntu is an African consciousness characterized by inter-connectedness of people, their communalism, solidarity, generosity, compassion, and care. Our suggestion is that we shift towards contextually-sensitive, population-based ethos as a strategy for engaging with under-served populations.

A population-based approach fundamentally shifts our professional thinking from the care of the patient to care of the population and, therefore, has an inherent inclusive interest (Keller, Schaffer, Lia-Hoagberg, & Strohschein, 2002). This approach is sensitive to the development needs of the general population as well as the specific needs of those with communication disability. Population-based intervention processes are by nature collective and collaborative and, therefore, include people with disabilities and communities. Developing equity-driven population-based approaches can be guided by critical engagement with questions such as: How can the collective interests of the population be advanced? Whose interests are currently served and why? What systemic/upstream factors impact on the current problems and what collective actions must be taken to change these? What is the notion of communication and communication disability in this population and, therefore, where should the focus of intervention be? Who defines, prioritizes, and participates in interventions? By what means will the outcomes be assessed? How will the resource-base be effectively utilized to enable equitable service delivery? What broad-based, cost-effective interventions will produce the greatest gains? How will individual need be met in this process?

There are emerging pockets of innovation in South Africa which illustrate sensitivity to under-served populations. Examples of such initiatives include:

• service delivery in vulnerable populations, for example, early communication intervention as part of primary healthcare package in a rural community (Levin & Edwards, 2007; van der Linde, Kritzinger, & Redelinghuys, 2009),

• telehealth supporting distance-interventions in under-served communities (Swanepoel & Hall, 2010),

• policies and practices targeting universal infant hearing screening (Swanepoel, Hugo, & Louw, 2006), and

• alternative service models and actions, for example, system-sensitive service interventions to address communication development of learners (Navsaria, Pascoe, & Kathard, 2011), and teacher-based intervention strategies (Wium, Louw, & Eloff, 2010).

These initiatives point in the direction of equity-driven population-based practices. As a further step, they must accumulate evidence of benefit and then be up-scaled and rolled-out at mass level to tangibly influence service delivery to under-served populations. SLPs as a collective must be proactive and visible in participating in these collaborative public initiatives to make our roles and contributions to nation-building explicit in the public domain.

Micro-level transformation

How can we translate the grand rhetoric of population-based approaches to what we do in our everyday practices? We suggest that consciousness-raising is a first step—as individuals and as a collective. This will enable a critical mass of people to engage practice differently. Developing alternative practices particularly in a Majority World involves risk and bravery because it transgresses the dominant model of practice, one that we know well and feel safe when associated with it. Transforming practices will mean that SLPs must foray, using big steps, into a world of uncertainty. Similar to Kamhi's (2011) suggestion to balance certainty with uncertainty, we offer the Relationship of Labouring Affinities (RoLA) (Pillay, 2003) as a consciousness-raising tool which has been developed to position SLP as a profession as an actor in the development of an egalitarian society. The RoLA uses communication, thinking, and labour as theoretical constructs to explain the ways in which SLP practices may be repositioned in the interests of social justice (see Figure 1).

Figure 1. The relationship of labouring affinities.

• Thinking is promoted as a contextualized process. Here, thinking refers to what we think, why we think it, who we think with, how we think when interacting, and where we think. Significantly, “where” refers to the social, cultural, and political contexts in which thinking occurs.

• Labour in the RoLA refers, quite simply, to our work—but within a Marxist tradition—where vulnerable people must also share labour and exercise control over their own lives and existence within clinics, hospitals, schools, their homes, and their communities.

• As communication experts, this third element—communication—is of inherent interest to us. We rely heavily on communication as a medium to “heal”. However, we attempt to know our patients/clients using the very thing that is problematic, namely communication. As such, the RoLA facilitates our thinking about how SLPs engage this practice dilemma of understanding people's experiences of living with communication disorders.

Given that under-served populations are managed inequitably and our suggestion that we should move towards a population-based practice, we can use RoLA's constructs to “let go” of practices which we don't find useful while “safely” finding new ways toward enabling and encouraging democratic practices.

Conclusion

We advance the view that Political Consciousness facilitates SLPs ability to hold equality and social justice as a lens for transforming practice. In using a political lens we identified selected forces and actions which help us to advance and impede change. Noting some forces at meta-, meso-, and micro-levels, we advocate an equity-driven population-based approach to practice as key to advancing services in collaboration with under-served populations. The combination of awareness and action at meta-, meso-, and micro-levels has potential to harness transformative practices that enable equitable service delivery to under-served populations. We must do this to ensure that we are relevant. Going forward, it is imperative that we develop a dialogue through genuine international engagement so that all, including the silent majority, are heard. This has to be done consciously, by engaging deeply entrenched political processes that maintain the current status quo in the SLP profession. We, from across the world, must examine how the nodes of power work in the profession and question why the Minority World continues to dominate practices and how the Majority World is complicit in this process. Dialogue, underpinned by Political Consciousness, is necessary so that we collectively take action for creating a more equitable world through our work.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.