Abstract
In part, this is a synopsis of a talk Professor Dean was invited to share with the physical therapy students at the University of Nigeria at Enugu in July 2005. At that time, the students honored her with an Igbo name, ‘Chinere’ – a true highlight of her career.
Even before being invited last summer to visit Nigeria by Dr. Mbah, Medical Director, University of Nigeria Teaching Hospital (UNTH), and Gloria Umerah, Assistant Director, Department of Physiotherapy, UNTH, I frequently pondered how best our profession can serve our global village. I had often reflected on Nelson Mandela's inaugural presidential address in which he quoted part of a poem by Marianne Williamson:
‘Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness, that most frightens us. We ask ourselves, who am I to be brilliant, gorgeous, talented and fabulous? Actually, who are you not to be?…Your playing small doesn't serve the world’.
These words also speak loudly to those of us in the physical therapy profession given the vast body of epidemiological and scientific evidence supporting our central role in addressing the health care challenges of the 21st century. When I reflect on how best I, as a physical therapist, can serve the global community irrespective of whether I am in a country described as low-, middle-, or high-income, I consider the definition of health advocated by the World Health Organization (WHO), the Hippocratic Oath, and the directions of contemporary medicine in our global village, as well as the definition of what it is to be a physical therapist.
First, what is a physical therapist? A physical therapist is a health care professional that is committed to wellness, health, and prevention, and the treatment of illness, disease, and disability by largely exploiting noninvasive interventions including education and exercise. Even though a physical therapist studies common content to a physician, the physician specializes in invasive interventions, namely, drugs and surgery. Thus, physical therapists work closely with physicians and other health care team members to prevent, cure, and manage the conditions of people in our society.
With respect to a definition of health, the WHO boldly described health in 1948, as ‘not merely the absence of disease’, but rather ‘psychological, spiritual, as well as physical wellbeing’. Based on this 55 year-old definition, ‘illness care’ rather than ‘health care’ tends to prevail. Much earlier, 2500 years in fact, Hippocrates wisely advocated that the principles of health care include: ‘First doing no harm’, and ‘That is better to prevent illness than to treat it.’ So-called modern health care appears to have lost sight of these noble principles.
And, with respect to health care trends, economic development worldwide has brought with it an affluent lifestyle that has not been consistent with good health, namely, the ‘diseases of civilization’ – ischemic heart disease, hypertension and stroke, diabetes, smoking-related conditions, cancer, and osteoporosis (indirectly) – the leading ‘killers’ and causes of disability in high-income countries and increasingly in middle- and low-income countries, accordingly to WHO reports. Furthermore, the WHO has acknowledged that the ‘diseases of civilization’ are largely preventable.
Even in economically-challenged countries such as Nigeria, the health and wellbeing of their populations are threatened with their economic development, by these lifestyle conditions as well as by acute infectious conditions such as respiratory infections, tuberculosis, and HIV/AIDS. The profession of physical therapy needs to rise up to meet these health care needs, and to devise a plan of action so the profession can exploit its expertise in addressing these challenges. This necessitates broadening the traditional scope of physical therapy practice in terms of ‘what we do’ and ‘where we do it’. We need to incorporate epidemiological indicators into our plan (that is, what are the major health care problems and how can physical therapy respond), to think and work outside the confines of hospitals and more in communities and villages. With respect to health education, we need to reach people globally through the media including radio, newspapers, presentations, and television to inform the various stakeholders about the role of noninvasive physical therapy prevention and care in addressing wellness and health, and managing chronic degenerative conditions. In addition, we can support public health initiatives regarding infection control such as condom use.
‘Being powerful beyond measure’
Our profession is being increasingly dominated by orthopedic and neurological specialization when in fact the health care indicators suggest another growth area. Even though we have a singularly important role in preventing and managing orthopedic and neurological conditions, clients/patients, adults and children alike, are increasingly presenting with one or more risk factors for one or more ‘diseases of civilization’. We need to assess our patients’ risk factors, and consider these as primary foci of intervention, regardless of the primary reason a patient is being seen by the physical therapist. We have prided ourselves in the past about our capacity to communicate. This skill is singularly important today in motivating people to lead healthy lifestyles and effect positive health behavior change. Sometimes the lack of resources can be a blessing. The basic diet of many Nigerians’ is a healthy one – lots of root vegetables, not too much meat, and little oil/fat, sugar, and salt. Provided of course a family is not starving, foods in Nigeria can be conducive to a good level of health. In addition, many people rely on walking to get around which is the best thing for their health.
Physical therapists use exercise to assess a patient's problem (or diagnose the problem), as well as prescribe it as an intervention. With economic development, people in middle- and low-income countries have more food choices (many unhealthy ones such as western fast food), thus, we have a responsibility to recommend good nutrition to people that will optimize their physical performance as well as their health. Likewise, smoking being the leading cause of preventable death in the world, we have a responsibility to assess the smoking behavior of our clients/patients, and be knowledgeable about smoking cessation strategies, and make appropriate recommendations. As health care professionals with a singularly important role in the leading health care challenges, physical therapists and students can have considerable influence in delivering health messages and objectively informing clients/patients about the consequences of their health behavior choices, and support healthy choices.
Because high-tech interventions have been inappropriately associated with providing quality care, we in the profession often take greater pride in a new piece of equipment, than in our capacity to assess and solve clinical problems in the absence of expensive equipment. The biomedical system tends to promote expensive interventions as being worthy, rather than noninvasive interventions to promote lifelong health and wellness, and prevent illness and disability. These are not costly interventions. Noninvasive interventions that can be exploited by physical therapists, largely education and exercise, can impact the lifestyles of a large number of people in a positive way, with low risk and low cost, with the promise of lifelong health. If we could put the effects of what we do ‘in a bottle’, physical therapists would be very wealthy indeed! Outside the realm of infection control perhaps, I would argue that physical therapists with their non invasive orientation, e.g., education and exercise, can address the cause of lifestyle conditions that biomedicine can not, in an economical and sustained way. The time has come to translate the existing knowledge about healthy lifestyles as primary components of our strategies and interventions.
Prospects for physical therapy students and new graduates in middle- and low-income countries
Those who are newly entering the profession of physical therapy have unprecedented opportunities, and these opportunities are on their doorstep. There is no better place to establish a leadership role for physical therapy in health care than in African countries such as Nigeria. Those who are creative and not afraid of challenge may establish themselves as leaders in the profession in a way that may be even more difficult in high-income countries. The profession in high-income western countries has become organized and hamstrung in a way that is constraining the capacity and growth of the profession, and in particular, its receptivity to addressing the health care priorities of those we serve.
Nigeria is a country rich in cultural and geographic diversity. So much of health care these days reflects people's knowledge about health, ill health, and beliefs and expectations about their health care, as well as actually seeking out health care. As health care professionals of the 21st century, we need to understand cultural distinctions within our global community, and address these in patient education. We need to be visible from the largest cities to smallest villages, from schools to businesses, from churches and temples to other places where people gather. Being hospital-based is too narrow for improving the health of Nigerians as most people are not in hospital. Radio is prevalent throughout the country, and many people have television. Physical therapists need to be in the media, in the newspapers, and broadcasting about wellness and prevention, and addressing general management issues. These initiatives are essential in health care in the 21st century.
Addressing our low professional self esteem
Noninvasive care needs to be exploited where and whenever possible. Noninvasive care may be indicated without invasive care (drugs). In many cases noninvasive care should be the first line of care, rather than being viewed as something done ‘after’ invasive care. In other cases, where invasive care, drugs, surgery, or both are indicated, noninvasive physical therapy may be needed in combination with a view to minimize the need for medication or potential for surgery over time, or for maximizing medical or surgical outcome. And lastly, by physical therapists’ fulfilling a more prominent role in health care – shoulder-to-shoulder with their invasive care counterparts, these physicians and surgeons will be able to use their skills more effectively. Biomolecular solutions, while mesmerizing, are likely to have a far greater impact after the confounding effects of lifestyle effects are controlled, rather than as primary lines of intervention. This is both economically and ethically defensible.
In the words of Albert Einstein, perhaps the most brilliant physicist that ever lived ‘We are limited only by our imaginations’. I urge physical therapists around the world to evaluate how we can best serve the people of the global village with attention to the leading health care priorities – the sky's the limit in terms of possibilities. A WHO health worker would be quickly dismissed, if in his or her village, that individual was focusing on parasites when malaria was the problem of the week. We must serve our society in the best way possible with our unique evidence-based expertise and skills, in a timely manner that is consistent with the priorities or our respective villages.