THE NEW INFORMATION TECHNOLOGIES: IMPROVING ACCESS OF DISABLED PEOPLE TO MASS COMMUNICATIONS

THE NEW INFORMATION TECHNOLOGIES: IMPROVING ACCESS OF DISABLED PEOPLE TO MASS COMMUNICATIONS

BARBARA DUNCAN
Rl Assistant Secretary General, New York, U.S.A.

Today we will hear about some major projects in Japan, Sweden, France and Spain to expand the access of people with disabilities to the mass media systems which are the primary contemporary communication linkages between people and their societies.

Traditionally, we have viewed the mass media as composed of the communications which take place in the press and on radio and television. Due to advances in technologies, we are now expanding our concept of the mass media to include other channels of communication for transmission of news, information, education and entertainment.

The once passive television screen is becomimg a tool for interaction; our telephone systems can now be linked to computers to deliver worlds of information and services to our homes and offices; satellite systems are bringing "distance education" to rural villages in the poorest countries.

Yesterday, the demand for the equality of use of buildings and transport dominated our discussions about accessibility for people with disabilities. Today, the need for accessibility of technology is becoming equally important to guarantee the equality of opportunity to education, information and training necessary for full participation in work and social life.

Since the invited speaker from the USA is unable to be with us, I want to inform the audience that the U.S. Technology Related Assistance to Individuals with Disabilities Act of 1988 became law this summer. It established a program of grants to the states to provide technology-related assistance to people with disabilities, as well as providing funds for programs of national significance. This is complementary legislation to another recent Act that requires technological equipment, such as computers, purchased with governmental assistance to be accessible to people with disabilities. Together, these laws are aimed at improving the accessibility and availability of new technologies to the U.S. disabled population. Another Act (The Americans with Disabilities Act) which will be introduced in 1989, and now gaining support, calls for among other things, equal access of the deaf population to television. This would require a vast expansion of the current subtitling and captioning program

A new Canadian report to the House of Commons, prepared by its Standing Committee on the Status of Disabled Persons, makes recommendations for changes in the Broadcasting Act now under consideration. Entitled "No News is Bad News", the comprehensive report calls for several specific measures to increase access to telecommunications and major expansion of captioning services on television.

In conclusion, I want to touch upon a perhaps obvious fact but one which is having immensely positive ramifications for disabled people. That is, that sophisticated equipment no longer equals expensive. This means, for example, that in many countries, as mass production realities take effect, a computer now costs less than a wheelchair.

The technological revolution we have been hearing about since the 1970's has finally taken place, and it is incumbent upon all of us to act so that people with disabilities receive a just and adequate share of the benefits.

TELECOMMUNICATION METHODS DESIGNED FOR DISABLED PERSONS

WATARU KURASHIMA
Integrated Communications Systems Sector, Nippon Telegraph and Telephone Corp., Tokyo, Japan

Most likely the need to communicate is stronger with the disabled person than with the able-bodied person.

Methods of communication are believed to have progressed considerably with the advances of technology. The methods that I am about to mention are related to telecomunication.

I have listed the major factors on Pages 3 and 4 with NTT products or test products already existing.

The requirements for this equipment is as follows:

1. For the benefit of elderly people, the equipment must be simple to handle and operate.
2. As is true with all telecommunication equipment, it must be economical and incoporate only proven features.
3. The equipment must incorporate fail safe features, thereby ensuring the users feeling of security.
4. In view of the increasing number of people who can work in their home, the equipment must be safe and compact.
5. The equipment must be useable without assistance from other family members or attendants.

The function of telecommunication equipment should not only be limited to communication outside. It has the potential of assisting the user in undergoing rehabilitation programs, thereby allowing him to become self supporting.

For the individuals undergoing rehabilitation that require visual communication methods at home, the cost can become prohibitive. However, work has already begun with the ISDN (integrated service digital network), whereby simple image communication can be conducted at rates equivalent to normal telephone calls. Soon it will become possible to educate using visual images.

For the disabled person, telecommunication is vital for emergency calls, health care and in overcoming feelings of desolation and isolation.

Many local municipalities have developed emergency calling systems with push button phones which can be installed in the homes of elderly and disabled persons.

Use of telephone cicuits for more thorough physical and mental care and services are under currently being researched.

For example, experiments are being conducted whereby a caller may contact a designated number and talk to someone who through a simple conversation can consult and help the caller overcome feelings of isolation and loneliness.

The idea of monitoring health data is in its final stages of development. It checks a mechanism which is activated when the individual goes to the toilet every morning and automatically conducts an analysis of the excrements, measures blood pressure and weight of the person. It then feeds this information back to a central station where the information can be evaluated.

Other methods being considered includes feedback to the rehabilitation staff so that they can continue their work with the most current information available to them. Information might include:

-UP-to-date information regarding machinery used in rehabilitation. e.g. use of videotax.

-Information on events relative to rehabilitation e.e. videotax

-Education relative to rehabilitation methods, e.g. use of videotax, nation- wide education with use of communication satelites as is currently used by Kawai-juku.

SWEDISH RESEARCH PROJECTS UTILIZING THE NEW INFORMATION TECHNOLOGIES FOR DISABLED PEOPLE

J.-I. LINDSTROM
Swedish Institute for the Handicapped, Bromma, Sweden

1. INTRODUCTION

There are many challanges in our time. Focusing upon disabled persons situation, perhaps the most important one is to see that the goal of integration, participation and normalization will be ful-filled. Or, in other words, that the gap between what disabled and non-disabled people can do will be minimized.

There are many ways to reach this goal. One makes use of modern technology. But modern technology also causes problems. Not per se, but because applied technology - regrettably - very seldom takes disabled persons' conditions into consideration. So, research and development on behalf of disabled persons has to be promoted along two lines, Viz. the adaptation of "common" technologies to include disabled persons' needs, resp. making use of technical achievments of our time for the development of special devices and services. In the following, examples will be given of both methods.

2. THE CONSUMER GROUPS

To be able to communicate is perhaps the most important ability of mankind. In a typical, industrialized country, the groups of communication handcapped persons are not very small. Minimum figures per one million inhabitans seem to be about 5000 visually disabled, 100 000 hard of hearing, 1000 profoundly deaf, 150 deaf-blind, 5000 speech impaired, 5000 mentally retarded and 10 000 motorically disabled persons. It should, however, be noticed, that those who have a poor eye-sight, who are hard of hearing or who do not, for intellectual reasons cope with their situation, are very well several times as many. - We know that, in developing countries, these groups are even larger.

3. TECHNICAL SOLUTIONS

My first example concerns a system for stop announcements in buses, trams etc. It is often a tricky task to get a proper stop information when using public transportation. Also, people who are deaf or hard of hearing have difficulties to catch spoken information. In some places in Sweden, a pilote project is running, where the announcement is made automatically both audibly <recorded, digitally encoded speech> and visually <on large LED displays>. This is an example of the statement, that what is beneficial to disabled people is also beneficial to everybody.

A second examole is queueing systems, based upon queue-number tickets. A system of this kind demands a fairly good vision, and consequently it causes problems to visually disabled persons. A pilote study is going on, where ticket stands have been equipped with an extra button, which - when pressed - activates a speech generator that gives specific information, a.o. about the ticket number. When it is the turn of that number, the speech synthesizer gets activated again and informs about the number and stand.

Text-telephones are in use within the community of deaf, hard-of-hearing, speech impaired and deaf-blind users on a daily basis. They are connected to the ordinary telephone network. Also connected are some Information Transfer Centers <ITC>, where hearing and sighted people have access to text-telephones as well as ordinary ones. Consequently, messages could be transferred via those centers from ordinary telephones to text-telephones and vice versa. Research projects are under discussion, where automatic ITC service should be provided with the aid of speech synthesis and speech recognition. For the closer future studies are going on about how to make use of what's called Chord Keyboards in the ITC service.

Deaf-blind persons can participate via text-telephones with Braille displays. On a pilote basis, a news service is provided for them so, that daily news are written down on a computer by a sighted operator and stored in the memory, connected to the telephone network via a modem. A deaf-blind text-telephone user is authorized to call the memory and read the information, i.e. a daily news service for deaf-blind people.

The radio network is per se an interesting tool for the transmission of information, and it could be used for many purposes. Already on a daily basis, 90 minutes recorded, spoken excerpts of daily newspapers are provided via the radio network to visually disabled subscribers. A special receiver with a built-in cassette recorder in the home of the visually impaired person, allows the "paper" to be recorded automatically, e.g. during the night. - An even more advanced possibility is to make use of the digitally stored information of the composing computers at the printing houses of modern newspapers. This information, i.e. the full content of the newspaper, can be extracted automatcally and transmitted in the same way as the recorded ones. Since one year some thirty blind persons are subscribing to the digitized version of the newspaper "Goteborgs-Posten".- Technical development as well as research in the field of behavioural science is going on in conjunction with the project.

In modern society emergency alarms are transmitted on certain occations, e.g. in events of big fires, industrial accidents, gas leaks etc. These alarms are almost always given as sounds, which could not be perceived by deaf persons and often not even by those who are hard of hearing. A research project is going on where radio signals in combination with tactile receivers will be used as a special alerting system for those groups.

Text terminals for information retrieval and communication are coming more and more in use. Research projects are going on with the goal of how to see if and how disabled persons can make use of the facility offered. - A special project concerns access to ordinary broadcast TV-programs for visually impaired people. Subtitles to translated conversation as well as the information value of the TV-picture itself is considered.

One of the very big possibilities for the future has to do with Communication and information based upon pictures. Deaf people look forward to a daily newspaper in sign language, distributed via the broadcast TV-network, like the abovementioned provision of newspapers for the blind via the radio network. Technically this could be done by using the TV-network when no programs are transmitted, and with an automatic recording on video-cassettes in the deaf persons home. - Deaf persons are also requesting picture transmission via the telephone network according to the ISDN standard, for the realization of remote sign language communication. - Even blind persons could benefit from the same kind of facility for the "reading" of various documents via special, manned reading centers - a kind of remote reading service for the blind. - Several projects on picture communication are under way.

4. CONCLUSION

The abovementioned projects are thought to be examples of problems and possibilities that are being tackled by means of research and development, studies, evaluations etc., in order to make it possible even for disabled persons to participate in the life of modern society. They are examples - which hopefully will be followed by others in a continously developing, industrialized society.

THE USE OF MINITEL BY THE DEAF POPULATION FOR COMMUNUCATION, PUBLIC INFORMATION SERVICES

R. BESSON
Centre National d'Etudes des Telecommunications, France

INTRODUCTION

Until 1986, persons suffering from a hearing or speech impairment needed a device acousticly coupled in order to carry out a normal telephone conversation. This system was unsatisfactory, due to the fact that it was only possible to communicate with users equipped with similar equipment and within a defined environment, thus in a "closed" communication mode. With the arrival of VIDEOTEX, and the distribution of hundreds of thousands of terminals, thus providing nationwide coverage, it was possible to foresee how disabled persons could avail of this extraordinary opportunity. By adapting the terminals which have access to a data base, in order to create interactive dialogue, it would be possible to enable persons with a hearing or speech impairment to communicate freely, in an "open" system. TELETEL'S development in France was going to enhance these possibilities.

VIDEOTEX IN FRANCE

B.1. General description

VIDEOTEX is an everyday reality in France for 3.8 million business and home users. It is also an economic reality for thousands of professionals in the telematic world.

The TELETEL service has been in existence for 8 years, thus the result of a long experience.

The terminal used for access to the data base is called MINITEL. It is easy to use, distributed free of charge, and replaces the paper telephone directories.

Users have access to approximately 8.500 services, through the public telephone network and the packet switching network. This is the equivalent of about 6 million hours of traffic per month.

The Electronic Directory, one of the most important services, receives 17% of calls made. The first 3 minutes of the call are free of charge.

KIOSL services allow service providers to be paid for use of their services without the trouble and cost of subscriptions, thus enhancing the development of the public service.

B.2. Teletel services

Electronic directory service

With Minitel, it is possible to obtain the addresses and telephone numbers of subscribers (24 million), on a round the clock basis, in metropolitain France and in the overseas departments. Professional and business information is also available (yellow pages) as well as information about other French P and T services.

Other services

TELETEL offers a wide variety of services both for the general public and business users.

B.3. The terminals

The range includes :

A basic terminal : the Minitel 1 (M1) and the Minitel 1B (dualstandard).
Teletel 40 columns, ASC11 80 columns.
This terminal is distributed free of charge.

The Minitel "Dialogue" (M1D), designed for persons with communication problems.
The rental cost of a terminal is 1.7 dollar per month.

Among the other Minitel terminals available on rental terms, there is the:

• Minitel 10 - M1 + a built-in electronic telephone set.
• Minitel 12 - MI B + built-in electronic telephone set + additional telematic functions.
• Colour Minitel.

Other TELETEL terminals :

• Minitel peripheral devices
  Smart card reader
  Printers
• Minitels outside France
• Minitel emulation by personal computer.

C - USE OF MINITEL BY PERSONS SUFFERING FROM A HEARING OR SPEECH IMPAIRMENT

At this point, we would like to present the use of Minitel by persons suffering from a hearing impairment. However, it is obvious that persons suffering from a speech impairment may also avail of this terminal.

C.1. Communication by means of text messages

There are four possibilities open to disabled users of Minitel in order to make a telephone call.

1. With the M1D through the public telephone network

The M1D is identical to the basic Minitel to which special functions have been added. These functions enable either all text or alternate text/voice communication with any other Minitel user.

The M1D enables off-line preparation of a text message (about 1000 Characters) and its automatic transmission once the correspondent has been called. Screen displays indicate progress in call establishment and when the call is terminated.

The M1D was made available to users in May 1986. There are 10.000 sets currently in use. The present distribution rate is approximately 400 per month. The call charging rate is the same as the standard telephone rate with the same reductions as for off-peak hours.

2. Calling the "36 18"

With any type of Minitel, it is possible to have access to a host computer (the call number is 3618) which automatically calls the correspondent (who is also equipped with a Minitel) and enables the exchange of text messages in an interactive mode.

For example, the charge of a 8' call is 1 dollar. The reductions are the same as for off-peak periods for the telephone. (On average 6000 calls per month are made).

3. Electronic mail (message services)

By dialling a number and using a confidential code, messages can be sent or received through the mailbox system (Mailbox, Direct conversation, Conference).

For example : by using a message service, deaf persons in France are able to communicate with deaf persons in Gallaudet College U.S.A. These mailbox systems are generally created by the deaf users.

4. A telephone exchange for the deaf

In the Paris region, an exchange operated by the P and T (French Telecom) enable messages to be transmitted between deaf users and persons not equipped with Minitel. These exchanges are staffed by special operators.

C.2. Information services

Deaf users can obviously have access to the Teletel services mentioned above by using the Minitel. Real-time access to a wide range of information is a considerable time saving and labour saving asset.

C.3. Special services

Regional organisations and associations of disabled users have helped in creating a variety of special services which include the following :

• emergency number access : fire station, police station. This service operates in the Paris region.
• SOS service in the Savoie region (fire station, doctors, hospitals).
• a taxi service available on Minitel.
• telegrams sent by Minitel.
• administrative information centers.
• transport information center.

C.4. Deaf users opinions of Minitel

The MID is now considered by deaf users as a means of communication comparable to that of the telephone. Its main advantage resides in the fact that it enables direct communication not only with other deaf users but also with persons of normal hearing.

The different mailbox systems are also seen in a positive light.

Despite the obvious advantages, Minitel is not yet used by the entire deaf population (only 15 % of deaf currently use Minitel). The reasons for this are as follows :

• the entire deaf population have not been informed of the existence of such a service. This is due to the fact that they do not all belong to regional organisations and are therefore not easily contactable.
• fear of using sophisticated new material is another reason (especially with the older population).
• certain deaf persons having difficulties in written expression are reticient to be exposed to ridicule.
• and above all, the cost of calls is an important factor which has delayed the widespread development of Minitel among deaf users.

C.5. Evolution

Surveys are currently being carried out, which will obtain information as to how the new basic Minitel will be developed in the future. These surveys take into account remarks made by disabled users.

A new Minitel, the M5, which has a flat screen and is portable is currently under study. It will be experimented for text communication with deaf users outside the home.

However, its advantages will decrease as more and more Minitels come into operation.

The introduction of public payphones using an phone card for M1D is also under study.

• The possibility of calling certain "Text Telephones" abroad exists also. (Belgium, Netherlands, U.K., Finland through the electronic mail).

D - CONCLUSION - REMARKS

Minitel has revolutionized the life of deaf users in the past decade. Remarks made demonstrate how this has been achieved :

Minitel has helped "to create an outlet to the outside world" and to give users "a new lease of life".

People with a hearing impairment now have the same access to Directory Enquiries as normally hearing persons, The majority of deaf users firmly believe that Minitel has increased the amount of information to which they are exposed. It has also helped in improving their writing skills (spelling, etc).

However, one fundamental problem remains the high cost of calls.

Finally,in conclusion, two remarks are worth mentioning :

• the MID is used by only a very few persons suffering from a speech impairment. The reasons for this are unknown.
• Minitels advantages for disabled persons are not limited to deaf users. Persons suffering from motoric disability can also have access to the vocal telephone system. Blind persons have access to TELETEL services by linking up a speech synthesis generator and a Braille generator.

COMMUNICATION TECHNOLOGY AND DISABLED PERSONS: FUNDESCO'S WORK IN SPAIN

RAMON PUIG-BELLACASA
FUNDESCO, Spain

To present some historical points about FUNDESCO's involvement in technology for special needs, I should underline that since the beginning of the "Foundation for the Development of the Social Function of Communications" in the 70's, several activities have been carried out concerning the use of information technologies on behalf of people with disabilities.

One of the general goals of FUNDESCO is to identify, promote and make possible through studies and experimental projects, social goals for the application of advanced information technology.

Initially we worked mostly in the promotion of ideas and debates on the issue which were becoming possible for the compensation of impairments and disabilities through technology and technical aids.

Since 1983 the logical next step has been to create some practical working groups, for example to study and resolve practical needs in the field of augmentative communication; cooperative projects, for example, to develop a telephone alarm system; pilot centers on augmentive communication and environmental controls. We were getting more and more funding from public bodies in order to support this line of work.

To proceed from projects to services has been the next step, especially after 1986.

Although our resources are small and our team is reduced, now we are considered and consulted as an expert body. We feel a great responsibility, because the "brain storming" carried on during the last years have produced many demands and high expectation. Anyway, we consider this rather positive, and now we are not alone, because university research groups, some companies and some public bodies (even if with too much structure and bureaucracy in our opinion) - are assuming these responsibilities in this field. Since 1975 or earlier, until now, the perspective has changed very much in Spain concerning communication and information technologies for disabled users in Spain,even if we are still very few and with little resources in comparison with the Nordic countries.

Methodology

FUNDESCO is not a company, is not an institution for care, not a stare body, but is a Foundation, and tries to be a "think tank" to push Spanish society ahead utilizing the best of advanced technology.
This means that we don't maintain stable services and even our projects always have a time limit. We try to link with national responsible groups, centers, etc: to increase their awareness. Also, working in cooperation with them to establish a solid experimental basis. Together, we aim to arrive at some practical conclusions, and to help them set up permanent services. The time involved varies but generally, from brain storming to the operational service can be 3 to 5.

This process can include:

• State-of-the-art reports
• Organization and monitoring of working groups, committees, expert panels, guided experiments, etc.
• Promotion and coordination of Research & Development projects
• Support for R & D projects promoted or coordinated by others.
• Study and design of solutions within the field of services and technological applications
• Seminars, courses, congresses, round tables, and other kinds of meetings.
• Exhibitions
• Participation in international committes, working groups, and societies.
• Various consultory and advisory works, as requested.

CONCLUSION

All our activity is dual faceted:

• reflection = perspective analysis, promotion
• application = research & development services implementation

Now we have a new president and during this autumn the priorities will be fixed for the next years. We are very hopefull that the activities related to disability and special needs are going to be reinforced. The focus will be slightly changed with the introduction of a new scope, that of "health and welfare" technologies. This will probably mean that a closer cooperation with other colleagues in the Foundation and a growth of the team working on disability issues will be two possible improvements for the future.

SPECIAL NEEDS POPULATIONS

THE VERY YOUNG

SPECIAL NEEDS POPULATIONS

THE VERY YOUNG

K.G.GURSU-HAZARLI
Hacettepe University Medical School, Department of Plastic and Reconstructive Surgery, Ankara, Turkey

Many of the world's influential policy makers and leaders in rehabilitation issues put more emphasis on the older population as a "Special Need Group" who becomes disabled due to acute or chronic diseases, or accidents, or just old age. Young ones with mental and physicial disabilities did not enjoy the same attention with few exceptions like cerebral palsy and polio until the last two decades.
The words of "Rehabilitation" and, "Disability" quite often are reminders of elderly and organic diseases, due to the fact that; greater percentage of disabled population is elderly. But this fact is may be due to the lack of proper data and the lack of sufficient research and studies on the causes of disabilities. For example the discovery of polio vaccine has prevented millions of polio disables, as reduction of premature births has prevented some cerebral palsy cases. On the other hand as we know mentally retarded children constitues 2% of the general population and these has been an increase in the survived numbers of severely mentally retarded children due to the reduction of death rate in this particular population and advanced mother and child care. Since 25-30% of all mentally retarded children are Mongols this also could be prevented by genetic councelling as well as studies like amniosynthesis during pregnancy by means of study of chromosomes and enzims in cells. We will be more effective in our preventive and rehabilitative actions if we know more about intrauterine chemistry, genetics and the incidence of certain congenital anomalies as well as other disabilities which are the results of malnutrition and environment during pregnancy. This means more research and more scientific knowledge is needed for prevention which is the key word disability prevention should be devided in to two major headings as: In developing and developed countries.
First-level prevention carries great importance in developing countries, since the major causes of disabling impairments in the developing countries are caused by preventable conditions, the most important ones being malnutrition, communicable diseases, low quality of perinatal care, and all kinds of accidents. These are responsible for about 70% of all cases of disability. Since the impairments resulting from these causes involve, to a large extent, infants and children, they are also the major causes of life-long disability. Thus the greatest impact of disability prevention measures can be expected among children consequently governments should give the highest priority to the implementation of the various components of disability prevention. Forthermore, since disabled infants and children experience higher mortality rates than normal children, the impact of disability prevention measures can be easily judged from the changes in their mortality rates. According to the report of "WHO Prevention of Disability" committee the situation remains unsatisfactory. While malnutrition had decreased in some countries, it had become worse in some others, notably in Africa where the per capita food production had declined. Disabling communicable diseases had been to some extent brought under better control during the last decade; for instance, smallpox had been eradicated and increased efforts had been made in some countries to immunize more and more children against poliomyelitis, tuberculosis, measles, tetanus, diphtheria, and whooping-cough. However, with respect to several others particularly malaria the situation is worse. Perinatal care is still very poor in developing countries and only an extensive coverage of the population with an adequate quality or primary health care is likely to reduce the incidence of disability related the perinatal period. Accidents also seem to be on the rise as a result of increase in road traffic and rapid industrialization; attempts in the past to deal with these problems have been inadequate.
In order to improve the situation in developing countries much more effective general and specific measures need to be applied more widely in the future. The general measures should include efforts to promote socioeconomic development and to improve the health status of some 800 million people who still live in absolute poverty. The specific measures relate to the development of the components of primary health care aimed at reducing malnutrition and communicable diseases, improving the quality of perinatal care, and reducing accidents and providing better care when they have happened. As it had been pointed out, prevention of impairment (first-level prevention) is the most effective way of dealing with the disability problem, and that attempts to cure, restore, or rehabilitate rarely give totally satisfactory results. Thus, despite both past failures of implementation and the likelihood of future problems in this regard, first-level prevention should be given overring priority by all national and international organizations. On the other hand in developed countries aboved mentioned causes, are of little importance as causes of disability. Accidents, however, seem to cause an increasing amount of disability, especially among the younger population. Thus, accident prevention should receive priority in developed countries have already implemented highly effective measures to reduce home and traffic accidents especially those involving children, through public education campaigns, improved safety measures, and legislation. Apart from accidents, diseases, such as rheumatic fever or metabolic disorders, genetically induced impairments, now cause the major proportion of all disabilities in children in developed countries.
It should be also pointed out that modern medical care aimed at prolonging life sometimes increases the incidence of disability as well. For instance according to Prof. Compbell, of Aberdeen University, "There must be limits to intensive care if it is not to become a new and potentially cruel form of child abuse. The decision that an infant would be better off dead is and awesome one but one that sometimes must be taken. The crucial question in deciding whether a baby's life should be saved or not must be the quality of life awaiting the child if it recovered. Neo-natal mortality rates had fallen in recent years to levels previously thought impossible and the successes of intensive care has come to epitomize the triumph of medicine.
High technology medicine is being increasingly use "relentlessly and indiscriminately" while too little attention was given to the wishes of parents and the pain and suffering of the infants. Guidelines for doctors from professional bodies and from hospital ethics committees are inadequate or unsatisfactory".
According to one estimate, in 1970 there were some 60-70 million disabled children in the developing countries; if existing preventive measures were not applied and new ones developed, that number could be expected to grow to about 135-150 millions in the year 2000. This may be compared with an estimate increase in the number of disabled children from 12 to 25 million in developed countries over the same period. In conclusing: Disability in youngsters should receive the same if not more attention and efforts as elderly, for each level of prevention and rehabilitation. It should be bared in mind that today's disabled youngsters will made tomorrow's disabled and special needs community.

THE ORIGIN OF DISABILITIES IN EARLY CHILDHOOD

- RESULTS OF A LONGITUDINAL STUDY -

K.-P.BECKER
Humboldt-Universitat zu Berlin, Berlin, D.D.R.

Ten years ago the Ministries for Health and for Education of the GDR's government asked for information concerning the phenomenology of disabilities and the prevalence of disabled children in its dynamic. This information is of great importance for the governmental long-term planning. The last figures based on scientific investigations were registered from 1951 till 1955. They do not satisfy the actual claims.
How to fulfill the expectations?
Two methods seemed to be applyable:
1. to calculate the prevalence of disabled children in its development by taking in consideration epidemiological factors based on our nowadays knowledge or
2. to investigate an unselected sample of children discerning their level of development and analyzing the causal conditions for disabilities.
We decided to follow the second one because of methodological reasons. One reason is that since 1955 so many alterations went on in social policy, hygiene, clinical medicine and education that our nowadays knowledge of the average level of development as well as of the origin of disabilities might be more or less changed. The second reason is that a paradigm of educational rehabilitation concerning the persons in need of rehabilitation is controversial to the definitions of the International Classification of Impairments, Disabilities and Handicaps.
In the meaning of educational rehabilitation the disability is not only a biological deficiency but also always a characteristic state of the personality. In general, the person in question is unable to meet the age-related social expectations-education, professional activity, family life and culture-without specific assistance.
A disability depends on:

1. A biological deficiency
2. A specific structure of personality
3. Inadequate social conditions under which a personality develops.

In our opinion a biological deficiency constitutes a necessary but not sufficient condition for causing a disability. A disability pertains to the total person, whereas a biological deficiency only affects the specific biological developmental conditions of a human being. Disregarding extreme instances, the social developmental conditions are the dominant in connection with the specific structure of personality.

Figure 1 Development of a Disability According to Educational Rehabilitation Theory

A disability is expressed by developmental conspicuousness in a variety of areas, i.e. areas of manifestation. These areas include sensory perception, motility, language/speech, cognition/memory and emotions under the perspective of performance and social conduct.
Following this paradigm we organized a longitudional study. 636 children were enrolled in the sample. In the beginning of the investigations, i.e. in the year 1979, they were in the age of 3;6 till 4 years, at the end in the age of 10;6 till 11 years. The territory where the children were living is typical for the German Democratic Republic from a demographic point of view.
An interdisciplinary team consisting of research workers experienced in the field of educational rehabilitation, language/speech pathology, medicine, psychology and social work as well as candidates in these fields investigated the total sample three times by using reliable and valid methods, namely in the years 1979, 1981 and 1983. Supplementary investigations were added in the years 1985/1986.
The collected data were checked statistically. In the process of a cluster analysis 8 groups were established.
The groups 1, 2 and 3 represent persons marked by developmental conspicuousness. The amount is dropping as the numbers of the groups are rising. The groups 4, 5 and 6 represent isolated kinds of developmental conspicuousness and the groups 7 and 8 persons with an actual personalities structure in the average and above.
Describing the conspicuousness according to the different groups we have found that the degree of a disability depends on the extent of the conspicuousness concerning the areas of manifestation, i.e. language aquisition/speech, cognition/memory, motility, social behavior and sensory perception. The extent can be recognized by the number of the affected areas of manifestation and the low c-values characterizing the conspicuousness, as it will be shown in the following figure 2.
See next page!
In group 1 all areas of manifestation are marked by developmental conspicuousness on a very low level of c-values.
Group 2 is characterized by three affected areas of manifestation in 4 varieties and group 3 by two affected areas of manifestation in 6 varieties.
The groups 4, 5 and 6 are characterized by one isolated area, either cognition/memory or social behavior or motility. In all these groups some minor visual and/or hearing impairments can be found too.

Figure 2 Degree of a Disability Characterized by the Extent of Developmental Conspicuousness in the Areas of Manifestation Concerning Group 1 at the Second Investigation of the Sample

Refering to the educational rehabilitation theory disabilities must be caused by the correlation of psychological, biological and social factors. Following this supposition the collected medical and social data were concentrated into two indices. Selected medical data were concentrated into a "Brain Damage Index", selected families education related data into a "Risk Families Education Index".
Table 1 shows the correlation between the different groups and the percentage of low c-values concerning these two indices.

Table 1 Correlations between Conspicuousness, Brain Damages and Disadvantageous Families Education

The fast correlation in the case of the first three groups is obvious, becoming continuously decreased in the line with the growing group numbers.
Conclusion:
We can confirm the paradigm of the educational rehabilitation theory concerning the disability according to this investigations. Preventing and intervening strategies can be derived from the results of the investigations very clearly.

References

1. International Classification of Impairments, Disabilities and Handicaps. World Health Organization, Geneva 1980.
2. Becker, K.-P. et al. Zur Genese und Phanomenologie physisch-psychischer Schadigungen im Kindesalter. Humboldt-Universitat zu Berlin, BERICHTE 1987, 7(5).

EARLY DETECTION OF DISABILITY IN CHILDREN

- EXPERIENCE IN JAPAN -

I.MATSUIa) and Y.KUROKIb)
a) National Children's Hospital, Tokyo, Japan
b) Kanagawa Children's Medical Center, Yokohama, Japan

Introduction

Early detection of disability in children is of crucial importance for providing medical care, rehabilitation and prevention of developmental retardation or impaired life.
There were marked decrease in the infant mortality rates and remarkable changes of the leading cause of infant deaths in Japan after the end of the World War II (1945). The deaths of infants due to pneumonia, enteritis or other infectious diseases were sharply decreased in this period, while infant deaths owing to congenital anomalies, birth injury, anoxic and hypoxic conditions remained unchanged. The program for detection of disability in children is controlled by the Maternal and Child Health (MCH) activities of the Ministry of Health and Welfare of Japan.

Maternal and Child Health Activities

In 1965, the concept of maternal and child health was clearly defined in the newly established MCH Law, which contributed to the improvement of the MCH level along with the social and economic development of this time in Japan.
The recommendations and activities for MCH and related medical services were established, and government-subsidized programs were made available to the entire population regardless of income.
Major activities in each period are listed below:
Pregnancy; Maternal and Child Handbook (1948)
Prevention program for vertical hepatitis B infection (1985)
Neonate; Mass screening for inborn errors of metabolism (1977)
Establishment of medical facilities for perinatal care (1984)
Infancy-Childhood; Regulation of Contag. Disease Prevention (1948)
Infant-Childhood health examination Programs (1948,1961,1977)
Surveillance of infectious diseases (1981)
Mass Screening for Inborn Errors of Metabolism and Congenital
Hypothyroidism

Newborns are screened within 5 - 7 days after birth for phenylketonuria, maple syrup urine disease, homocystinuria, histidinemia, galactosemia and congenital hypothyroidism for the past ten years in Japan. The rate of implementation of such screening has reached 99 percent of total births.
Every year, nearly 500 infants screened are put under medical care for metabolic disorders without developing the peculiar symptom of the defects.

Health Examination System for MCH Service

The MCH Service in Japan includes a nation-wide Health Examination Program for infants and children. All prefectural and regional Health Centers and related facilities play very important roles in these Health Examination Programs.
Every infant receives a health check at early infancy (3-4 months), late infancy (8-10 month), 1 year and 6 months, 3 years of age, offered free of charge. On occasion of suspected physical or developmental delay, the infant is referred to a special clinic in the Children's Hospital or University Hospital etc. under governmental and prefectural subsidy.
Early detection of disabilities in children under the above health check system is very effective.

Birth Defects Monitoring Program

Several projects dealing with a Birth Defects Monitoring Program have been developed in Japan in recent years. Each Program established the baseline incidence of several major malformations such as anencephaly, cleft lip/palate, Down's syndrome or other surface malformations.
The final goal of the projects is the early detection of increased rates of malformation in the population, followed by rapid detection and removal of the possible teratogen. The system however, can be available for other purposes, such as early detection of the handicapped and offering medical care for the defects, or genetic counseling, etc.

A STRATEGY TOWARDS EARLY IDENTIFICATION AND EARLY INTERVENTION OF HANDICAPPED CHILDREN, WITH SPECIAL REFERENCE TO DEVELOPING COUNTRIES

KURT KRISTENSEN
Kenya lnstitute of Special Education (KISE), Nairobi, Kenya

According to WHO, approximately 1 million children in Kenya betweer 0-15 years of age suffer from a handicap to a smaller or greater degree.

In 1984, the Government of Kenya, with the support of the Danish Government, decided to establish Educational Assessment and Resource Centres. The projects aim was to establish an assessment centre in all of the country's 41 districts.

Initially 17 Educational Assessment and Resource Centres were established throughout the country. Today a centre has been established in each of the 41 districts and approximately 25,000 children have received services from the centres.

The justification for the establishment of Educational Assessment and Resource Centres was among other things, that before the establishment of Educational Assessment and Resource Centres, the training and education of the handicapped was begun once the child reached school age instead of at a much earlier age.

One third to one half of all handicapped children in many special schools were incorrectly placed, due to lack of assessment before the children were admitted to special schools.

Only a small proportion of handicapped children (1-2%), received training and formal education.

There was a great need in Kenya for programmes which could provide early identification and early intervention of handicapped children, and for well structured integration programmes. The Educational Assessment and Resource Centres were established with these objectives in mind.

The activities at the Educational Assessment and Resource Centre consist of:

Assessment of all kinds of handicapped children between 0-16 years. The assessment is carried out by an assessment team consisting of assessment teachers and personnel from the Ministry of Health, Ministry of Culture and Social Services and other non-governmental organisations.

Guidance for parents with handicapped children is given after the child has been assessed at a centre. Parents receive guidance on how to handle the child and where to look for help from other agencies. In order to follow up this guidance, the parents can be invited to visit the centre again at a later date or staff from the centre can make a home visit.

Parents' courses are held at the centres. During the courses, the parents are given information and advice, through practical demonstrations, on how to handle a handicapped child and how to make simple aids.

For groups of children who live fairly close together, self help groups are encouraged.

Integration of handicapped children into ordinary schools is possible in many cases with help from an assessment teacher, who travels around ordinary schools in which handicapped children are integrated, to give those children extra support. The peripatetic services are based at the Educational Assessment and Resource Centres.

Establishment of units in ordinary schools has been done in areas where there are a great number of handicapped children. A unit is an ordinary classroom, where a teacher teaches a group of not more than 15 handicapped children. Approximately 100 units have already been established as a result of the assessment services.

Assistance with the establishment of small homes is given where children could be easily integrated into ordinary schools or units, but the walking distance between home and school is too great. For these children, small homes have been established. A home is an ordinary house where handicapped children can stay from Monday to Friday or in some cases all week. A housemother takes care of the children.

Referral of handicapped children to special schools is only done if the child's problems are profound and his/her needs cannot be catered for in an ordinary school.

Provision of equipment at some of the Educational Assessment and Resource Centres is made by a workshop which is attached to the centre. Here, information materials, teaching and simple aids can be produced. The centres may hold models or samples of teaching and mobility aids which can be reproduced by parents, local artisans, youth polytechnics, prisons and other workshops. These materials and aids may be used to support or fit handicapped children being assessed and those enrolled in the surrounding schools.

Many handicapped children are referred for medical examination and/or treatment by the centres.

Holding of seminars for teachers and others is done by the assessment teachers who hold short inservice courses in how to train handicapped children, for teachers administrators, health and social workers and the community.

Collection of information about handicapped children for use as the basis of the central planning of special education, surveys and research.

One Educational Assessment and Resource Centre in each of the country's 8 provinces acts as a main centre. These centres have more advanced equipment than the others.

An Educational Assessment and Resource Centre is situated in each district in connection with a special school or unit for handicapped children. The headteacher has overall responsibility to the Educational Assessment and Resource Service. The work is carried out by an assessment team.

One hundred and twenty eight sub-centres have been opened by the 41 Educational Assessment and Resource Centres so that no parents of handicapped children have to travel long distances to obtain assessment services for their handicapped children.

Various services exist in Kenya for handicapped children, but these resources have not always been effectively co-ordinated. One way is through the Educational Assessment and Resource Centres.

Information about the Educational Assessment and Resource Centres has been given to the public through all possible means. People have to know about their existence in order for them to be optimally utilised.

In conclusion, an Educational Assessment and Resource Centre is the most cost-effective special education service for handicapped children, because early identification and stimulation are stressed, thereby preventing unnecessary effects of a handicapping condition.

In developing countries it is necessary to establish systematic, decentralised programmes for the handicapped. It is not sufficient to set up a few isolated programmes of integration which often fail because of lack of follow-up. Integration of the handicapped has not been achieved in a country until almost everybody has been integrated and accepted at some level in the family and the local community. Another pre-requisite is that any regular school class, no matter its size, must include handicapped children.

References

1. Kristensen Kurt The Special Pedagogical Centre for Education, Training, Research, Technical Aids Development and Information. Educational Rehabilitation, School Psychology, Hans Knudsens Plads 1 A, 2100 Cologne, FRG
2. Kristensen Kirsten Guidelines for the Establishment of Educational Assessment and Resource Centres. UNESCO, Ed. 86, 5 - January 1986.

A DIMENSION OF REHABILITATION SERVICES PROVIDED BY MCGILL UNIVERSITY IN A REMOTE AREA OF CANADA EASTERN ARCTIC - N.W.T.

B. DESTOUNISa) and D. MACLEODb)
a) McGill University, Montreal, Quebec
b) Health and Welfare Canada, Ottawa, Canada

INTRODUCTION

In 1981, when the International Year of the Disabled Persons came to an end, the representatives of the European Communities stated at the General Assembly of the United Nations: "In long term, the prevention of disability is undoubtedly the most important problem to be tackled .... all rehabilitation measures start with prevention, early detection, early treatment and medical rehabilitation" (RENKER, 1982).

Data from many countries indicate that 10% of children born are either born with or acquire, physical, mental or sensory impairments that interfere with their capacities for normal development. This is a minimum estimate. Numbers can be much greater, ranging to 15-20% of all children depending on the conditions included, and the definitions of disability.

Industrialized areas report a reduction in the incidence of disabilities, but underdeveloped countries or rural areas show a much higher percentage of disabling conditions. Available data indicate that 15-20% of the total population of these countries suffer from disability (KAFKA, 1973).

Low standards of education, hygenic conditions, lack of trained personnel, information and communication are some of the contributing factors for the increase in the number of disabled persons (INGSTAD, 1983).

The development of Rehabilitation Services in isolated areas is a challenge. The variance in culture and customs plays a significant role. Consistency and reliability of qualified professionals is the major factor contributing to success in the development of Rehabilitation Services. Professionals working in rural, underdeveloped areas suffer from isolation and lack of professional stimulation. The rate of turnover amongst the professionals in extremely high, which creates a major problem in the development of a service.

BACKGROUND

The Northwest Territories is the most remote and underdeveloped area of Canada, having a unique culture and extreme environmental conditions. This area is subdivided into three main zones, the Inuvik Zone, the Kewatin Zone and the Eastern Arctic Zone, which includes Baffin Island and surrounding islands.
McGill University, for the past 25 years, has been providing consulting physicians from its teaching hospitals on a regular basis to the Baffin Regional Hospital (BRH). This 35 bed hospital is the only primary health care facility in the Eastern Arctic. It is located in Iqaluit, the capital of the Eastern Arctic. The total population in this area is approximately 8,500, made up of 85% Inuit and 15% white people.

There are 12 settlements or small communities located in the Eastern Arctic. The population varies from 150-700 people. Present, or affiliated with every settlement, is a teacher, social worker and nurse. There are nursing stations in each settlement. The nurse or nurses are responsible for the health care of the community, such as delivering babies, organizing various types of clinics for children and adults and taking care of all traumatic incidents. When serious emergencies arise, the patient is sent to the BRH by airplane or helicopter, as this is the sole means of transporation. Communication systems between the nursing stations and the hospital exist through telephone or FAX system.

Prior to 1978, very few disabled children lived in the Arctic. They were either forgotten and left to die or sent to an institution in southern Canada for specialized schooling, rehabilitation services or long-term "placement". The child was subjected to a vastly different culture as well as environmental conditions that created many additional problems. When the child became a young adult, or when services were no longer required, the youngster was returned to his settlement in the North.

Re-integration into his community was devasting to both the child and the family. This young adult no longer spoke or understood Inutituk, nor had he developed the skills necessary for survival in the north. It is only in the last 8-10 years that parents have been advised to keep their handicapped child at home. It is possible for a family to arrange home activities to cope with the disabled child but this is only possible if practical assistance from public agencies, relatives and friends or both are available (INGSTAD, 1983). In the rehabilitation of a child, the family as well as the extended family play a significant role in the care and process of development (SCOTT, 1984).

METHODOLOGY

Now that the children were kept in the settlements, the need to provide services was apparent. The Baffin Regional Hospital formed a contractual agreement with McGill University giving them the responsibility to develop and provide such service. This originally started in 1984. A Rehabilitation Team was formed which consisted of a Coordinator of Rehabilitation - who had experience in all disciplines of Rehabilitation and the mandate to develop Rehabilitation Services - a physiotherapist and orthopedist. The team expanded in the four years to include a neurologist, occupational therapist, speech pathologist, child development therapist, seating technican and a specialist in deaf education. Visits were made from 2-4 times per year depending on the needs indentified. The resource team assessed children and provided consultation to teachers, social workers and nurses.

Prior to the development of a service, the prevalence of disability has to be examined. One of the problems encountered was the absence of reliable data regarding the number of physically disabled, the nature, the degree and cause of handicaps. The need for quantitative data was necessary for the execution of effective programs for the disabled (GEHANDICAPTEN, 1976).

The nurses from the settlements were contacted and asked to refer to the BRH all children at risk or with a disability, to be assessed by the consulting Rehabilitation Team. Each child had a written evaluation by the orthopedist or neurologist, physiotherapist and other if deemed necessary.

RESULTS

In the four years, 80 children were identified and followed for treatment. They were moderately to severely disabled.

28% had a neurological impairment affecting their physical abilities;

30% were developmentally delayed and functioned more than 3 years below their peers;

26% had secondary neurological disabilities resulting from an infectious disease, such as meningitis, encephalitis (mental and physical disabilities);

16% had acquired handicapping neurological and orthopedic conditions from trauma or other psychological cause.

These results are consistent with the world statistics on the prevalence of disability in underdeveloped countries which is in the 15-20% range.

DISCUSSION

Although 80 children were identified, it is believed that only children requiring help in daily living activities and in mobility were referred. Parents of handicapped children, functionally independant, would not necessarily present themselves to the nursing station. It is probable that children with very visible characteristics of handicapping conditions were identified. Therefore, the prevalence of twenty percent is a conservative estimate if all disabilities of minimal to moderate are to be considered. The results also showed that the prevalence of disability amongst children 0-9 years was much greater than 9-18 years.

An additional finding amongst the professionals, teachers, social workers and nurses, in the remote settlements, was the lack of professional stimulation, the feeling of isolation and the need to consult with specialists in the field of rehabilitation to help them deal with the moderately and severely disabled children and their families in the community. The general knowledge of professionals, as well as the general public, in the area of rehabilitation, preventative measures and equipment recommendations for children is limited.

It was also found that the average stay for a nurse, teacher or social worker in a settlement was just under two years. Recruiting staff for this area is a challenge.

CONCLUSION AND RECOMMENDATIONS

In the four years the researching data and information showed that consistency and expertise in the area of rehabilitation are needed. This can be provided through a contractual agreement with a major university that has the resources available to provide the expertise and consistency required for the solid development of a service.

The most significant factor necessary is the participation and involvement of the Aboriginal people themselves if the project is to succeed. The objective of the development of Rehabilitation services is that, the local people, the Inuit, become part of the process through education, training and sensitization in disability. The local people, as in any other cultural group, will respect and have confidence in a person from their culture. They feel more comfortable discussing issues in their own language rather than through an interpreter. They are aware of what is acceptable in the community and what is possible. Their innovative ideas of simplicity are feasible and acceptable to the cultural environment.

Examples of participation of the Inuit in this project are as follows:

1. A parent of a handicapped child was trained by the developmental therapist, physiotherapist and occupational therapist to work with the children 0-5 years. This infant program was established in Idaliut. The parent was paid by the hospital, and she visited parents at home, taught them particular therapeutic and program strategies to help in the development of their child. This base will be used to serve as a resource to people identified from other communities to start a similar project.
2. The physiotherapist taught the handyman (carpenter) in the hospital, basic principals in design for the equipment needed for the handicapped child. This decreased the number of pieces of specialized equipment that had to be ordered from catalogues in the South which often proved inappropriate and excessively expensive.
3. A public health nurse in BRH was trained by the audiologist from McGill to perform audiological screening tests. She travels throughout the communities and refers any children suspected of a hearing loss to the consulting audiologist visiting the BRH.
4. McGill University, through its teaching hospitals, is providing physiotherapists to the BRH on a rotational basis. The minimum stay is 3 months with no maximum indicated. This sensitizes professionals to a different culture, provides experience not available in general hospitals and stimulates interest in the development of services in remote areas.
5. McGill University, through a contractual agreement with the BRH, has provided a consistent service by having the same professionals involved for the four years. The role of the consultants was important to the professionals in the area. They provided a professional learning experience to nurses, teachers and social workers who perform extraordinary work in isolated areas. The people working in remote areas need positive feedback, reassurance and the opportunity to discuss relevant issues which became available to them.
6. A parent support group was established from a conference sponsored by the Rotary Club of Baffin Island. The parents had the opportunity to discuss, ask questions and learn. Personnel from the Hospital and Rehabilitation Team took part in this conference.
7. McGill University, through the Faculty of Education, is providing a special course in child care at the Arctic College. McGill also provides a specially adapted curriculum in the Faculty of Education to encourage Inuit people to become teachers. Plans for future training include programs in the Faculty of Physiotherapy and Occupational Therapy. This will provide the needed help in the settlements where a support service of physiotherapy and occupational therapy are required.

CONCLUSION

The prevalence of disability in the eastern Arctic is high. A future project, if disability is to be prevented and reduced, is to research the determinants of disability in the Arctic. To conclude - McGill University through its affiliated teaching hospitals provides and promotes health care services and educational services to rural areas of the North, stimulating local participation and staff training - "Building a Shared Vision".

REFERENCES

NEW REALITIES IN VOCATIONAL TRAINING AND PLACEMENT FOR PERSONS WITH DISABILITIES DURING PERIODS OF ECONOMIC CONSTRAINT

VOCATIONAL TRAINING UNDER ECONOMIC RESTRAINTS FOR DISABLED PERSONS

- NEW FACTS RE THEIR EMPLOYMENT -

SATSUO NAGATA
National Vocational Rehabilitation Center, Saitama, Japan

"Vocational Training and the Securing of Employment" for disabled people is an objective which we have striven to promote continuously. It's an area that is automatically known to suffer from numerous social and economic restraints.

The fact that this Sectoral Session has selected economic restraints as the subject for discussion is believed to be for the following reason:-

Social restraints would, for example, include such areas as social customs and education levels, which are slow in undergoing change and therefore likely to be overlooked. There are also other areas experiencing changes, such as the medical field. However, to date, we have been unable to capitalize on the results in a way which gives immediate use and application.

On the other hand, there is no way of measuring the effects of economic restraints in our areas of interest. It's a fact that all activities are influenced in some way. Economic restraints are the result of economic cycles of prosperity and recession, and require our constant attention. I believe that our failure to cope with the changes will result in our returning to the same, meagre beginning from where we started in days gone by.

To assist the smooth progress of this Session, I should like to mention briefly the most serious problems in terms of economic constraints confronting us today:

First is that fact that the modern-day labour market continues in a state of incompletion. There are developing nations plagued with high unemployment, and there are other nations - whose economies have declined in recent years - also faced with increasing numbers of unemployed people. In such nations there are acute problems in securing employment opportunities for disabled people, as well as in developing effective measures of vocational training.

One way to assure such employment opportunities has been for disabled people to be placed together in one special facility. This continues today amongst developing countries.

However, usually the work is simple, basic, requiring that workers receive little training or prior instruction. Yet these days there is much work available which calls for special skills, and I believe it will become necessary for everyone to undergo effective and practical training sessions, even if only short-term, before going on to employment.

Disabled people's employment opportunities normally undergo a steep decline when the economy is in a depressed state. On top of this, funding of vocational training and placement centers is trimmed throughout. Thus, the impact of "economic restraints" is felt in the true sense of the word. There is little either you or I can do individually about this situation.

Yet, economic recessions should be just the times when serious-minded enterprises seek qualified and competent employees when looking for additional mapower. There are disabled people who are as qualified - if not more so - than nondisabled people.

The important point is to establish a system whereby the desires and requirements of employers seeking to recruit additional staff can be made known. Once the disabled worker has been recommended and selected by employers, I believe it is vital that contents of their training curricula should be revised boldly and without hesitation to match the requirements of their new employer. This will encourage a system whereby training in specific, selected abilities can be given for a suitable time - as individually required in each case. It should remove rigidly fixed concepts to which personnel in charge of training have steadfastly clung in the past, typically asserting that "unless certain requirements are met, it cannot be recognized as vocational training". Though I cannot state this with certainty, I believe this would create progess in a direction that would be welcomed by organizations that are providing financial support.

Second, there is the question of whether development of auxiliary assistive devices and specialized, assistive, operational tools may expand employment opportunties for job positions heretofore regarded as impossible for certain categories of disabled persons. Coupled with this would be the question of whether disabled persons would have expanded opportunities for new job positions made possible by technical innovations.

Recently, increasingly light-weight materials with additional strength have been developed, resulting in progress in the area of auxiliary assistive devices. Advances in micro-electronic technology have brought about successess in new automated equipment applicable in various areas. There is every possibility that disabled persons will increasingly be able to use this type of equipment in their work situations.

Progress in the medical fields have been remarkable, and I feel the need to establish close working relationships with these areas.

Although there may be need for certain considerations in some cases, I personally should like to see disabled persons meeting the challenge of seeking employment in the new work situations developing because of the above technology. They should not avoid such opportunities simply because of their disability.

Third, is the problem of developing new methods of training disabled people to give them the technology and skills required by prospective employers.

I have already mentioned the importance of being able to grasp the desires and requirements of prospective employers with regard to training given. By training methods, I refer to the action of selecting the technology and skills to be included in the training curricula according to the wishes of the recruiting organization. The curricula needs to be also arranged and structured to facilitate training sessions, which should be easily understood and absorbed by the trainees.

Fourth, is the problem of assistance to developing nations seeking to set up systems of rehabilitation for disabled persons. The condition of "being under economic restraints" would be the exact situation in which developing nations are finding themselves.

Establishing facilities and providing equipment will remain important factors in economic assistance over the future. But I believe that assistance and guidance by specialists in transferring of technical skills and knowhow, together with receiving trainees into rehabilitation facilities of advanced nations, to be vital factors.

I trust that this brief outline will help us in these Congress discussions, and in our future work.

APPROPRIATE MODELS FOR TRAINING DURING PERIODS OF ECONOMIC CONSTRAINT

J. ALBERS and H. GEERDINK
Centrum Beroepsopleidingen 'Hoensbroeck', Hoensbroek, The Netherlands

Processes of change on the macro level of society can be of influence on the labourmarket position of handicapped and in this way indirectly these processes of change can force vocational rehabilitation to renew services and products but also to consider new ways of promotion and distribution. In this perspective one can find in societies social, demographic, economical and institutional macro processes of change, processes which can have interdependent relationships.1) 2) Institutional changes cover the social security system and the disablement acts that are concerned and also the operational practice in the rules and regulations.
Changes in the economy cause subsequent changes in supply and demand for labour with respect to quantity as well as quality. Also technological developments have consequences on the labour market. 3) The demand for the quality of labour can change and the amount of labour per unit product can lessen.

The market-adequacy of models for training for persons with disabilities in vocational rehabilitation depends in considerable degree on the possibility to assimilate the significance of these relevant context factors in the perspective of goals, organisation structure, facilities and resources and characteristics of the target population.4)

The employmentstructure has changed profoundly in The Netherlands.5) The economy shows characteristics of a shift to a post-industrial or information society. Despite economic growth and despite the increase of employment since '85, structural unemployment seems hard to be reduced. In 1985 40% of all non-handicapped unemployed had only primairy or incomplete secundairy education. In 1980 an investigation 6) showed that in a representative sample of disabled people under the Incapacity Insurance Act about 80% had an education level of primairy school or lower vocational education.
There are expected trends of changes through automation in employment, organisation of companies, work content and skills required.
Automation appears to have an impact on the required qualifications for jobs as well as the character of these qualifications. The employment for people with higher-intermediate and high level education - especially for the technically trained - appears to be stable. The employment for people with lower education appears to decrease.7) The exact effect appears to depend to a large extend on the way jobs are being composed. Most companies tend to change the organisation from production oriented to market- or client oriented, which demands flexibility in production process, organisation and personnel. Companies tend to separate higher (programming, planning, etc.) and lower (operation, controlling, data-entry, etc.) skill tasks in different jobs.
There are indications that for a large group of disabled persons employment chances seem to decrease with the diffusion of automation. This would concern somewhat older people with stress and wastage symptoms and lower education.
For a small group of young handicapped people with a clearly determinable impairment and a higher education level, employment chances seem to increase. 8) 9) 10)

According to research reports 11) the decline in the number of employees in The Netherlands reaching the age of retirement in good health - able to work - is alarming. The increase in number of people who are permanently disabled is not only confined to the older age groups, but increasingly concerns younger people and middle-aged employees. Recovery - being able to work - following a period of one year disability is limited and in fact this only occurs in the first two years and within the younger age groups.
The Dutch act on the employment of disabled workers of 1986 (WAGW) makes it obligatory for firms to stimulate equal employment opportunities for disabled and non-disabled workers and to improve the capacity of disabled workers to earn their wages, especially by adapting jobs.12) A quotum which enforces to employ a certain number of disabled workers may follow.
From studies 13) 14) of companies it appeared that most large companies have no direct intention to actively recruit disabled persons from outside, but that their policy will be trying to keep disabled employees on their jobs or replacing them in their company. The act probably accentuates more prevention of job lost than reintegration of handicapped that already lost their jobs. Once unemployed, people with disabilities experience much greater difficulty than non-disabled in securing alternative work, in this aspect a strategy concerning prevention of job lost can be fruitful for those still in the working force and at riskfor work handicaps and joblessness. Vocational reintegration facilities remain of importance for groups like youth-handicapped who have not had an opportunity to work. But also for handicapped with work experience that could not be replaced in their company. Prevention and reintegration measures should function complementary.

In the above context vocational rehabilitation has to meet needs and has to formulate goals. Not only in the field of reintegration but where possible also in the field of prevention. Both fields may need goal-adapted structures for training and different organisation models. The function of prevention and reintegration measures should be complementary.

In the fifties and sixties a period of economic growth employment oppportunities were rather good. Short training programmes and placement strategies for semi-skilled and unskilled jobs could be succesful, also for reintegration purposes for handicapped. For the future there is a forecast of a decrease in the availability of lower skilled jobs so competition between handicapped and non-handicapped in this area will increase. To be succesful it can be expected that training models in the field of reintegration will demand structures that produce favourable and qualified vocational profiles for competition on the free labour market.7) 10)
This implies for vocational rehabilitation in the field of reintegration that training programmes have to meet certain conditions like appropriate training time to reach the needed higher skill levels or the knowledge and skills according to formal qualification standards; technical equipment according to the standard of enterprises; adequate learning materials preferably in module form and instructors that are familiar with working with new technology systems.15) 16) The labour market developments demand sensibility on the part of vocational training organisations for vocational opportunities for the disabled. Adequate information structures and if possible cooperation with firms and for example apprentice system for this purpose will be needed.
For the group of handicapped people who do not have the potential or possibility to follow training and education on a higher skilled level - which offers a better position on the labour market - training for more lower skill or routine functions, for which there is demand, for example in the field of lower skilled automation functions, can be fruitful. Additional support in job seeking and securing will probably be needed. Vocational training can be arranged in a model that permits the handicapped to develop multiple practical skills in a certain function or task field. In this way even on a lower skill level the flexibility can be enlarged. The training programme could include various periods of practical training or workorientation in firms and maybe probational periods.

The prevention strategy of job lost for disabled can be accomplished by retraining programmes and replacement eventually with job adaptation, worksite modifications, technical aids etc. within the company. There are clear advantages compared with the reintegration model. The vocational rehabilitation process is more direct in time, can be shorter, can be less costly and more direct related to the work environment. If more time consuming retraining for a new position within the company is needed, the possibility of job reservation can be considered and discussed with Joint Medical Service (G.M.D./social security). A strategy for prevention of job lost for workdisabled towards firms is to be optimal effective dependent on the support it meets in these firms.
Conditions in firms like the attitude towards workdisabled; attention to working conditions and human resources; the economical, organisational and personnel facilities for a structured job retention programme are important. Job adaptations related to the former tasks or functions, replacement within or outside the former department with on the job training or training outside the firm can be simple but also very complex depending on the conditions within the firm, the disability - and person characteristics involved and regional factors, when services from outside the firm must be called upon. Good communication, coordination, assessment of person and task environment, workload and workcapacity and an evaluation of process and outcome will be needed. Concerning training it must be determined what possibilities there are within the firm and when training organised by regular or commercial training institutes in the region or by specialised vocational training services for the handicapped are needed.
When despite prevention- and reintegration measures work cannot be secured for certain groups of disabled because of a shortage of suitable jobs, this can imply more pressure on the sheltered work system that however is confronted with a zero-growth. These conditions probably make consideration of possible alternatives for work or alternative work very necessary.

References:

TRAINING FOR SELF AND GROUP EMPLOYMENT CREATION IN AFRICA

R. RANSOM
African Regional Advisor on Vocational Rehabilitation, International Labour Organization, Addis Ababa, Ethiopia

Introduction

An estimated 80-100 million new jobs must be created by the 52 countries in Africa between now and the year 2000, according to a recent ILO study.1 It predicts that by the turn of the Century, the economically active population in Africa will reach 318 million men and women, out of a total population of 871 million, as these future workers have already been born. Compared with an estimated 214 million workers out of a total population of 555 million in 1985, this growth represents the highest rate projected among all the regions of the world.

To absorb this massive increase in the workforce, as well as to productively employ the millions who are presently unemployed or underemployed, African governments are faced with the impossible task of creating approximately 7-8 million new jobs per year. For this reason, employment creation has become the major preoccupation and priority in the national development plans of most African governments. Yet virtually all African countries are experiencing serious difficulties in achieving the economic growth required for job creation.

Among the working age population in Africa are men and women with physical, sensory or mental impairments, who are able and want to lead economically productive lives and contribute to the development of their communities. Estimates vary, but as many as 1 out of 10 persons in any country in Africa may be disabled as a result of illness and disease, home, work and traffic accidents, faulty practices surrounding birth, poverty and malnutrition, civil strife and warfare.2 Among the estimated 50% of disabled persons who are of working age, many are employed or working on their own. The vast majority, however, have little education, no vocational skills and few resources with which to earn a living, and remain dependent upon their families and communities, often through begging, for survival.

New and urgent employment strategies and action are required if governments in Africa are to survive, let alone respond adequately to the challenge posed by unprecedented population and workforce growth. New strategies and action are also required to assist the growing number of blind, deaf, physically disabled and mentally handicapped youth and adults of working age in Africa to become economically self-reliant.

Present Efforts

Existing vocational rehabilitation, skill training and work preparation programmes for disabled persons, operated by both governments and non-governmental organisations in Africa, reach only a tiny minority of those in need and often fail to lead to any type of productive employment. Vocational training is usually institution-centered, and trade-based, providing training for a 1-2 year period in skills such as woodwork, leatherwork, metalwork, tailoring, secretarial skills, etc. leading to a trade certificate, and hopeful formal sector employment in existing businesses, industries, workshops, etc. Yet due to high competition with non-disabled workers trained in virtually identical trades, few disabled trainees find jobs. Several countries have tried to reorient their formal vocational skills training programmes for disabled persons by emphasizing self-employment as a goal and providing tool kits and materials to graduates. These efforts, however, have not significantly increased the number of disabled trainees who become economically self-reliant.

Recently, great interest has been shown, both by governments and non-governmental organisations, in the establishment of decentralized, non-institutional, "community-based" rehabilitation services for disabled persons, often linked to existing primary-health care, community development or social welfare systems. However, present "Community-Based Rehabilitation" (CBR) programmes in Africa have made little impact in meeting the vocational skill training needs of disabled youth and adults, and have not been very successful in mobilizing local community resources to assist disabled persons to become self-employed.

Another approach used by many governments in Africa to meet the employment needs of disabled persons, namly direct employment in the civil service, has now reached its limits. In fact, many governments are currently facing financial crisis and are reducing the number of government employees as a part of "Structural Adjustment Programmes". Unfortunately, disabled civil servants are often the first to be let go.

Proposed Strategies

What can be done in Africa to more effectively prepare and successfully ensure disabled persons a productive life? Two strategies are proposed which are not entirely new, but while more appropriate to the realities facing disabled persons in Africa, have yet to be implemented on a wide scale.

Strategy No.1 - Training for Rural, Farm-Based Self-Employment
Approximately 70-80% of the population in Africa lives in rural areas and depends upon subsistence farming for a living. Disabled youth and adults living in rural areas should be encouraged, prepared, and assisted to participate in the farm-based economy through integration in existing farmer-training programmes, access to existing agricultural extension services and credit schemes, as well as through special training programmes (i.e. for blind farmers). Training should be product-oriented based upon local market demand, tailored to the capabilities of the individual, and include a "package" of skills necessary for the individual to become self-reliant, including production, harvesting, marketing, and financial management skills.

Examples of successful farm-based activities by disabled individuals in Africa include vegetable gardening, flowers, fruits, cash crops (tea, coffee), poultry raising, pigs, rabbits, goats, cows, bees and fish-farming. Examples of processed agricultural products produced by individuals and groups of disabled persons in Africa include jams and jellies, honey, cheese, spices, wax, dried fish and dried flowers.

Training for Rural Self-Employment may be decentralized or institutionbased, but should always have as its objective the successful settlement or resettlement of the disabled individual on his or her land in an income-generating activity. Rural rehabilitation centres established for this purpose should set the example by being themselves self-supporting in food through agriculture and livestock production. Follow-up extension services to resettled trainees should be an integral component of Training for Rural Self-Employment.

Strategy No.2 - Training for Urban, Informal Sector Self & Group-Employment
Many disabled persons in Africa, particularly those that have had access to an education, live in towns and cities, but despite their education and possible vocational skill training, remain unemployed. Formal sector employment opportunities are, and will remain, limited for both disabled and non-disabled workers alike in urban areas. However, informal sector production and service activities have become the largest and fastest growing sector of most African country economies3, and offer the best hope for economic self-reliance for disabled urban dwellers.

Training of disabled persons for such urban, informal sector, self as well as group, employment should be product or service based, rather than formal trade-test oriented courses, as determined by market demand and available raw materials. The list of potential products or services is endless, but examples of successful productive activities by individuals and groups of disabled persons in Africa include the manufacture of mats, carpets, baskets, ropes, cloth, clothing, shoes and sandals, sweaters, furniture, doors, windows, utensils, brushes, brooms, pottery, cook stoves, tricycle wheelchairs, jewelry, decorative crafts, handbags, greeting cards, calendars, toys, dolls, chalk, candles, and artificial flowers. Service enterprises run by disabled persons in Africa include shoe repair, watch repair, bicycle repair, laundry, typing and secretarial services, computer-services, printing services, tailoring, motor-rewinding, electrical appliance repair, automotive repair and retail trade.

Training for Urban, Informal Sector Self and Group Employment means business management training, which requires a training "package" of skills such as determining market demand, business planning, product design, production and quality control, marketing, financial management, use of credit, in addition to basic training in the appropriate technical skills. As is the case for Strategy No.1, Strategy No.2 requires follow-up business advisory services, access to credit, and assistance with feasibility studies and marketing to achieve its objective - disabled persons earning income and living economically self-reliant lives.

Organisations of disabled persons have a role to play in assisting the self-employment of their members through the establishment of revolving loan funds and the provision of technical and business management assistance, both to individuals and group production workshops, cooperatives, etc. Such assistance, however, must be based on a fundamental principal: nothing is free in life, and disabled persons must be expected to contribute to or pay for all material, financial or other assistance received in the same manner required of non-disabled persons.

ILO Activities

In Africa, the ILO is presently implementing technical cooperation projects, funded primarily by the UN Development Programme, in the field of vocational rehabilitation with governments in 10 countries, including Ethiopia, Kenya, Lesotho, Madagascar, Malawi, Nigeria, Sudan, Togo, Tunisia, and Zaire, and has proposed projects in 10 additional countries. Many of these projects include direct support for the creation of income-generating activities by disabled persons themselves, in both rural and urban areas, and/or the introduction of the training strategies outlined in this paper. In addition, over the last four years, the ILO has been collaborating with the African Rehabilitation Institute, headquartered in Harare, Zimbabwe, in the development and field-testing of methodologies for the delivery of community-based vocational rehabilitation services and support for the creation of income-generating activities by disabled individuals and groups.

It is still too early to evaluate the impact of these initiatives on disabled person employment in Africa, but the ILO is committed to effectively addressing the priority need and desire of disabled youth and adults in Africa: economic self-reliance and productive participation in the economic life and development of their communities. This commitment is reflected in ILO Convention No. 159 and Recommendation No. 168 concerning the Vocational Rehabilitation and Employment of Disabled Persons, adopted by the International Labour Conference in 1983, and is confirmed by the Khartoum Declaration of the United Nations Economic Commission for Africa, "Towards a Human-Focused Approach to Socio-Economic Recovery and Development in Africa", of March 1988.

Conclusion

The vast majority of the working age population in Africa that is disabled can and want to lead useful, productive lives. Present vocational rehabilitation efforts are inadequate. The realities of labor force growth and present economic constraints facing governments in Africa require new approaches to preparing and assisting disabled persons to become economically self-reliant. Two strategies are proposed for training disabled persons for either rural, farm-based, self-employment or urban, informal sector, self or group employment in Africa. Both emphasize the orientation of skills training towards the provision of goods or services required in the local community, the use of locally available new materials, the acquisition of business management skills, and the establishment of follow-up systems of advisory extension services, technical assistance and credit. The ILO is presently introducing these proposed strategies through its technical cooperation programme in Africa. But more countries need to adopt such "training for self-employment" programmes for the estimated 5-10% of their growing working-age population that is disabled.

References

1. Economically Active Population Estimates and Projections, 1950-2025
   International Labour Office, Geneva, third edition, 1986
2. World Programme of Action Concerning Disabled Persons
   United Nations, New York, 1983, p.11
3. ILO Jobs & Skills Programme for Africa (JASPA)
   "Recent Trends in Employment, Equity and Poverty in African Countries" United Nations Economic Commission for Africa, Addis Ababa, 1988, p.6

AN ASIAN APPROACH TO VOCATIONAL REHABILITATION OF DISABLED PEOPLE THROUGH COMMUNITY BASED METHODS

IAN F.TUGWELL
International Labour Office On project mission to Dept. of Social Welfare and Development, Philippines

In 1984 the Philippine Department of Social Welfare and Development embarked upon a community based provision of vocational rehabilitation to disabled people. The objective was to perfect a method which would serve vastly greater numbers than was possible in the four existing government run vocational rehabilitation centres. These four centres offer around 300 rehabilitation courses each year and the non governmental organisations do not significantly increase the provision. Against this it is estimated that around one million Filipinos are in need of vocational or vocationally related rehabilitation services.
The scattered nature of the Philippine population throughout its archipelago of over 7,000 inhabited islands and the marked regional and provincial differences strongly indicated the need for the development of rehabilitation services at community level. The United Nations Development Programme and the International Labour Organisation (ILO) provided funding and technical assistance.
From the outset it was intended to develop a general prescription for community based vocational rehabilitation but one which would accommodate variations necessary to meet very localised needs and conditions. It was, and remains, an experimental project, although during its four years life enough has become clear for some general guidelines to be laid down and for several features to be accepted as essential to the method.
The recent widespread use of the term community based has seen it applied to such a range of activities and programmes that some limitation seems required. The Philippine project accepts the following definition: 'Community based: a planned programme of positive action which has its origins and its primary focus of service and resources within the community in which it is operational. A community based project is one which is not imposed from outside and is recognised by the community at large as necessary and desirable for them.'
And we further define the term 'community' as 'all the people of the barangay (village), municipality or city. Especially the people of the barangay in which the disabled person and the community rehabilitation volunteer are resident'.
In designing the project it was considered that, by working through the government infrastructure, it would be possible to mobilise community effort and interest at barangay level by the utilisation of indigenous community resources and voluntary service from private citizens.
When introducing the service to a community, a public awareness exercise is mounted. This requires discussion with local officials from provincial governor downwards and, ultimately and most importantly, with the majority of the village people themselves. Verbal explanations and fact sheets written in local dialect together with the photographs of project activities and results are used. After the public awareness meetings and discussions, candidates for community rehabilitation volunteer are invited, from which one is selected. This is followed by a five day basic training course; the syllabus for which has been an ILO input but future training will be conducted by the Filipino staff.
Immediately following training the volunteers start work among the local community and develop a small caseload of disabled neighbours with rehabilitation needs. It is considered that five active cases is a suitable caseload for a trained and experienced volunteer to handle.
Community rehabilitation volunteers have the following role activities and responsibilities:

1. identifying the disabled client;
2. making contact and forming a relationship with the client and the family;
3. helping the client and the family to identify their needs and plan rehabilitation goals;
4. identifying and mobilising the resources of the community;
5. ensuring that the planned steps to rehabilitation are carried out and
6. keeping the local community interested and involved.

With such a comprehensive role, basic and refresher training must concentrate on practical issues and on giving the volunteers the know-how to do the job.
Volunteers enter into a commitment of nine hours service each week. The best volunteers are people busy in their own livelihood or domestic duties; people from the informal sector, resourceful individuals, well known locally and good role models for independent livelihood. Typically they are farmers, fishermen, housewives, engineers, basket weavers/handicraft workers, nurses and small scale business entrepreneurs. Unemployed college graduates, of which the Philippines unfortunately has many, do not make good volunteers: the best drop out when they leave home for their own careers, the ones that remain unemployed are unlikely to have the personal initiative essential for effective volunteering.
Rewards and incentives for volunteers have been the subject of experimentation. Initially all were paid 50 pesos(US$2.50) monthly from government funds. More recently in new project sites there has been no payment, without any discernible difference in effort and results.
The volunteers are initially given close support and a degree of professional supervision by social workers in the government service. The quality, availability and continuity of such support is considered to be vital to the success of the method. None-the-less as the volunteers and the communities involved become more confident with the methods, they assume a greater measure of responsibility and autonomy. The support and the backstopping ideally should be perceived by all as being on tap rather than on top. For there can be little value in the use of volunteers for the delivery of community service if they become just a cadre of unofficial helpers at the bottom of a civil service dominated structure.
In the Philippine project, emphasis is placed upon the use of resources of skill, assistance and finance existing within the family and community of each disabled person. Volunteers are enjoined to 'think family first and think barangay community next' both when identifying the required resources and when determining responsibilities. For the volunteer is the catalyst to action by the community, and not the sole provider of the services.
To date, 400 volunteers have been trained and fielded. The resulting service has reached 1,500 disabled people. Many of whom have developed a degree of independence, new skills and functions, and an estimated 400 are engaged in livelihood/income generating activities. Due to severity of disability, remoteness of home, unwillingness to leave the family, or by being too young or too old, many of the beneficiaries of this community based service would not have been suitable for centre based rehabilitation even if it were available.
Community rehabilitation volunteers must be recruited from among the local population in which they are to be operational. They must serve that cluster of households around their own which form the community they know and are known in. A rough guide to the maximum size of that area might be the 400 households nearest to the volunteer's own. Given an average household size of 6.5 people a volunteer may serve a community of 2,600 people. Such a population is likely to contain 50-60 disabled people in need of vocationally related rehabilitation help. More than enough to keep the volunteer busy for several years.
In rural and isolated communities it is likely that, through the extended family system, the volunteer will be related to a large part of his or her target community and will have had some social contact with most of the rest. Therefore the volunteer is essentially a 'good neighbour': but a good neighbour whose willingness to help the community is fortified through training in rehabilitation thought and method.
Within this community of neighbours the volunteer will be extremely effective in tapping local resources. Firstly, the resources of goodwill and interest, which will be the greatest among those who know the disabled client and who may share in the rehabilitation process. Then in tapping more specific and practical resources such as local skills, the loan or use of tools, access to materials and markets, assistance with transportation and, eventually, with livelihood opportunities.
In such ways the community becomes the project. Provided they are kept informed and involved and are encouraged by the volunteer to share in the rehabilitation process and to enjoy its successes, a whole force of neighbour power can be mobilised.
A recent development has been to pilot the method, so successful among the rural populations, in the apparently less cohesive and less stable communities of some economically depressed areas in Metro Manila. Early indications of its acceptability and probable effectiveness there are encouraging.
During the pilot phase, the project has undergone a number of modifications in design and method. Interestingly, the ideas which have proved least effective have been these intended to structure and support the project activities; such as municipal 'action teams' to coordinate and improve access to infrastructure services, and the development of project focal points intended to be local service centres meeting the needs of both the disabled population and the cadre of rehabilitation volunteers. These concepts have added little to the effectiveness of the service and may even endanger it by creating unnecessary bureaucratic procedures. The lessoon is that simple services leading to simple solutions are best and that the true focal point should be the home and family of the disabled person.
Success or failure depends upon the capacity and courage of project planners, rehabilitation professionals and volunteers to be revolutionary and innovative; to eschew the use of standardised, centrally administered programmes as the only way to meet individual needs. And to resist the temptation to bureaucratize a community service programme by sucking it back into a government department.
Even if vocational rehabilitation centres were highly effective, costs would prevent the provision of enough such facilities in most Asian countries. But where there are no rehabilitation centres we can turn communities into 'centres of rehabilitation'. The method developed in the Philippines has been tested in remote rural communities, semi urban settings, depressed areas of metropolitan Manila and has been acceptable to both Christian and Islamic communities. It would be suitable for adaptation and adoption in other Asian countries and possibly elsewhere in the developing and developed world.

MODEL FOR THE VOCATIONAL TRAINING OF THE DISABLED IN JAPAN

TETSUO CHIKUMA
National Vocational Rehabilitation Center for the Disabled, Saitama, Japan

1. Vocational Taining as a Component of the Vocational Rehabilitation Process

The ultimate goal of the social independence of the disabled is to make disabled people occupationally independent, and enable them to participate in social and economic activities together with able-bodied persons.

For disabled people to be able to work under competitive conditions with able-bodied persons, they must acquire the ability to perform a job equally well or even better than ablebodied persons. Herein lies the need for providing vocational training for disabled persons.

For a long time, disabled persons used to receive medical rehabilitation at hospitals, psychological and social rehabilitation at welfare facilities for the disabled, and vocational training at vocational training centers.

As these facilities carried out the services under the unique plans of their own, there has been overlapping of or gaps in the services provided, sometimes making disabled persons bear unnecessary large expenses, or causing them to feel uneasy. The National Vocational Rehabilitation Center for the Disabled (hereinafter referred to as NVRCD) is located in the same campus with the national Rehabilitation Center for the Disabled established and run by the Ministry of Health and Welfare, and provides, under mutual cooperation with the latter, such services as medical care, functional training, training for daily life needs, vocational training, vocational guidance, employment counselling, post-placement workshop adaptation guidance, etc. consistently in a planned and continuous process.

2. Circumstances around Vocational Training of the Disabled

In Japan, there are a few factors which public institutions must pay attention in providing vocational training to disabled persons.

Firstly, there is a need for responding to the changes in the manpower demand-supply relations, which are being caused by the rapid shift of our country's social and economic situation to a domestic-demand centered economic structure.

Secondly, there is a need for coping with the rapid increase in the number of severely disabled persons as well as the diversification of disabled bodily parts. Namely, there is a sharp decline in the number of persons disabled by surgical diseases such as caries and polio, and drastic increase in cases of diseases of nerve center such as cerebral palsy and spinal cord injury, and severely disabled such as hemodialysis.

To cope with such situation, it has become necessary to carry on day-to-day continuous health check-up.

The third is the issue of the budget and capacity of public training. The State budget is placed under a severe constraint, as its ordinary expenditure must to saved and the personnel strength needs to be curtailed.

3. Management of Vocational Training at the NVRCD

The NVRCD runs short-term vocational adaptation courses and long-term vocational training courses. The characteristics of these vocational training courses is that all disabled persons, whether enrolled in short-term or long-term courses, can enjoy the system of individual vocational counselling, which means that one and the same counsellor continues to give counselling to a particular disabled person from the time of his admission till he becomes occupationally independent.

In addition, the Center accepts trainees at any time, who may finish the training course when they have reached the training target. This is called the system of admitting and leaving the course at any time. The training is individualized and centered on practical exercises. In conducting training, a particular trade is not specified for a trainee. Instead, a trainee is required to take a course designed to cover a group of trades, and, after considering the result of the basic training, detailed training target is set for him, and under the modular system of training as a unit, a curriculum adapted to the ability of the individual trainee is formulated.

When a individual trainee's progress justifies, his original curriculum may be changed, and the duration of training may be extended.

In order to support these activities, practical research and studies are being undertaken at the Center, such as the development of individual learning system, etc. Up-to-date technologies which make use of the results of such research and studies are being used at the workshop.

4. Results

During the past 8 years, a total of 1,100 disabled persons have been trained, and the placement ratio of these trainees is 90 percent. Even severely disabled persons can receive vocational training through systematic rehabilitation, and today it is possible to secure competitive employment opportunities for them.

5. Proposals

Based on the 8 years' record of training disabled persons at this Center, we would like to make the following proposals concerning the vocational training of the disabled.

1. to give vocational training a position within the system of total rehabilitation which should be as consistent as possible.
2. The contents of training should be framed individually, while evaluating the ability of a disabled person, and in such a manner as to suit the result of such evaluation.
3. The contents of training should be constantly modified so that they may respond to the needs of the enterprise.
4. The organization of training should be so flexible as to meet an increase or decrease in the number of trainees.

MODEL FOR VOCATIONAL REHABILITATION FOR DISABLED PEOPLE

M. A. A. EL-BANNA
Council of Rehabilitation Research, Ministry of Social Affairs, Egypt

Vocational rehabilitation and employment of the disabled is a very essential part of the rehabilitation process. In nearly all countries of the world, rehabilitation starts as vocational rehabilitation. It is interesting to note that in Old Egypt the Pharoes had a system for vocational rehabilitation: they employed the mentally retarded in arranging the clothes in the cupboards and bead work. The blind were trained to be singers in the temples.

In modern Egypt, rehabilitation services started in the fifties from the Department of Vocational Research in the Ministry of Social Affairs. A network of rehabilitation offices and four comprehensive centers for the rehabilitation of blind, deaf, physically handicapped and mentally retarded were established during the period 1950 - 1968. This was accompanied by training of manpower for these services.

Now there are fifty-six rehabilitation offices and thirty-five comprehensive rehabilitation centers all over the country. The main function of this system, apart from providing specialized and comprehensive rehabilitation services, is the assessment and vocational training of the handicapped. After the vocational training is completed a rehabilitation certificate is issued to every disabled person, stating their medical condition, type and degree of disability, the vocational training program undertaken and the type of job he can perform.

By Egyptian law there is a quota of 5% in all jobs in the private or public sector for the disabled, provided that the agency employ more than 50 people.

This is the official, formal system for vocational rehabilitation in Egypt. During the period 1975 - 1987, 15,165 disabled persons had been employed through that system.
It is worth noting that once a disabled person obtains a rehabilitation certificate, he can access to employment immediately, in comparison to nondisabled individuals who have to wait 1 - 2 years to get a job.

However, it was also realised during these years that although this system may be quite suitable for the mild or moderately disabled, yet it was inadequate for the severely disabled or those with multiple handicaps.

So, in 1974, a research project was conducted by the Ministry of Social Affairs and the Department of Health Education and Welfare of the United States' government, concerning rehabilitation of the severely disabled or multiply handicapped. The objective of this program was to obtain satisfactory employment at the optimun level for the severely handicapped.

152 severely disabled persons (118 males, 34 females) between the ages of 18 - 40 years were selected for this program. Mental retardation combined with other disabilities constituted the major etiological factors in this group, together with neurological conditions such as C.P. and M.S. and myopathies.
The research was led by a team of experts in the rehabilitation profession. The vocational training program took place in six rehabilitation centers in Cairo. 118 of these cases were employed in the following jobs: book-binding, rug-making, bamboo furniture, shell-work handicraft, knitting, leather work, weaving, packing, car polishing, car mechanics, office work, tailoring, and small enterprises such as vending stands.
Follow up of these cases with inventories to test vocational adjustment, economic adaptation and personal and social adjustment showed satisfactory results.
There were 34 cases unable to adjust to this program, mainly because of the presence of mental retardation (low I.Q.) and emotional instability, but although they failed to gain employment, these cases showed improved self-independance and better social adjustment in their families and communities.
A cost-benefit study showed that this program does yield in economic as well as personal and social returns.

The experience gained from this research had encouraged and motivated the Council for rehabilitation research to try a new service model for vocational rehabilitation of the severely and multiply disabled using community resources and avoiding institutional training in sheltered workshops. This is mainly to reduce costs, and at the same time maximize the vocational adjustment and social adjustment of the disabled in their families, communities and work environment.

The hypothesis of this model is to utilize knowledge, skill and experience of professional vocational counselling to identify abilities of the severely handicapped together with their vocational potential on one hand, and on the other hand, undertake a realistic search for job opportunity in their accessible environment.
Then a suitable match is done. The vocational training is done if needed on the work-site with the cooperation and participation of the employer. It must be noted that placement in this model avoids lots of the problems which resulted in failure to rehabilitate the severely disabled in other programs. As an example, the jobs chosen for the disabled are near their homes or accessible to their families to avoid transportation problems. Job modification and also elimination of architectural barriers are seldom used. A lot of attention is paid to eliminate negative attitudes towards the disabled in their families and their work environment. Counselling is available for their personal, social and vocational adjustment.

To test this model, 253 severely disabled males with ages ranging from 18 - 60 years were chosen for the program. 80% of these were aged between 20 - 30 years, only 3 cases were aged between 40 - 60 years. The etiology of disability was a combination of physical and neurological - only 3 cases of mental retardation were included in this group.

This group were employed in the following jobs:

secretaries - 15; administration - 17; clerks, helpers - 28; typists - 4; advertizing - 1; doctor - 1; telephone operators - 3; teachers - 7; engineers - 1; electrician - 2;

Social adjustment rated 81% in this group, vocational adjustment rated 73%. The average income earned by this group is equal to and sometimes more than the national average of able-bodied persons. No one failed.

It is worth noting that only one professional vocational counsellor was responsible for this program, helped by part-time staff, e.g. medical rehabilitation specialist, social worker, psychologist.

This model reduces the cost of the vocational rehabilitation program by 50% and also resulted in more effective placementing of the severely handicapped.

It it also worth noting that high professional skill is necessary to try innovative models of vocational rehabilitation, especially in conditions of economic constraint. That could call for urgent need for training of rehabilitation counsellors to increase their skill and knowledge to be able to utilize science and technology for the benefit of the disabled, especially in the developing countries.

DESIGN AND USE OF APPROPRIATE TECHNOLOGY

DESIGN AND USE OF APPROPRIATE TECHNOLOGY

TOMAS LAGERWALL
ICTA Information Center, Bromma, Sweden

Appropriate Technology for many people means bamboo, leather strings and other very simple materials. This is the case in particular when talking about appropriate technical aids for disabled people. These kinds of materials may be the most appropriate in a certain area for a certain group of people. But I do not think that it always gives the right concept of the word appropriate. There are at least three aspects that have to be considered when the word appropriate is being used:

• the economic or rather the socio-economic aspect,
• the cultural or rather socio-cultural aspect, and finally
• the technical aspect.

The world develops and changes continuously. Plastic products, they were something not very commonly in found industrialized countries 25 - 30 years ago, are today found all over the world. In more and more countries in the third world plastic products are available. By using modern materials better solutions can be achieved.

Modern materials, like plastic products, may imply risks for the people who work with them and also for the users. I think it is very important to bear this in mind when looking at new technology.

The use of appropriate technology is sharing of knowledge with the people in the community. The technology should cater to the needs of the neediest (i.e. the rural and the urban poor), which generates self-reliance (and not overdependence on external resources) and which is in harmony with our environment.

AIDS MADE FOR INDIVIDUAL USE OF PHISICALLY SEVERE DISABLED

YUJI MITSUNO
Misakae-No-Sono, Mutysumi-No-le Nursing Home for the Severely Disabled, Technical Aid Department, Nagasaki, Japan

When I worked as an industrial designer at a design laboratory of a certain home electric apparatus maker fifteen years ago, I often asked myself, "For whom am I making these goods? Do they make anyone happy?" One of these days I happened to meet a child with severe disability and this gave me the answer.
I, with some of my friends, made an aid for his bathing, playthings forcing him to use both hands and a training aid which helps him stand up with his own feet. I didn't know these were successful works or not, but anyway I could surely felt satisfaction with the work with a definite purpose and a person to use. I found our technique would support someone. Few people engaged in the field of this work at that time, so two comrades and I started a small work-shop named "DEKU KOHBOH"
Most of the orders we got were chairs for children with cerebral palsy who were unable to sit to eat and to play. Others were: designing and making of chairs for excretion, aids and playthings for special training, development of china dishes with an original shape and function, sometimes building and reforming of a house, and planning of a small welfare facility.
After that, in 1983, I got a job at the present nursing home, Misakae-no-Sono, as a staff of technical aid department.

1. Some of our works made for individual use
Works at Misakae-no-Sono as well as those at KOHBOH (work-shop) are basically made for individual use ordered depending on "the situation". I mean the situation the part where troubles occur.
We never think of "disability" itself as a trouble. We understand the troubles are those resulted from disability in daily life, and our duty is to support these people by making some kinds of aids. It is usually done by a team of staffs in rehabilitation. I think it necessary to tie up with other technitians as orthopaedic aids makers and architects. The following examples show such a joint work.

1) A chair for a child with hydrecephalus
He is unable to support his huge head with his own neck. It 's also a hard work for him to lie down. Therefore I, cooperated with an orthopaedic aids maker, made a reclining chair with head supporter. The special structure enables him to move his head right and left without other's help. Small and safe reclining system was realized by utilizing a jack of a small car.(Figl)

2) A dining chair
It is a matter of course that chairs for physical disabled should be made suitable to his physique and degree of his ability, and his way of life at the same time.
In Japan, the western style of taking a meal has become popular, but the traditional Japanese way with a low table sitting directly on the floor is still found in many homes. So before starting to make a chair, you must know in which way he takes a meal in his home, otherwise he is forced to have a meal alone separating from his family.( Fig.2)

3) A toilet for an old lady with cerebro vascular disease
This is the case of an old woman who returned home after the training at a rehabilitation center. The problem was that she had to stay home alone for some hours in a day and had nothing to do without other's help during that time. We, members of DEKU KOHBOH, discussed the problem with the physical therapist, the woman and her family. She never wanted to use a diaper. She said she would return to the hospital if she was forced to put it. Our members with the therapist found that whe could move crawling on the tatami mat to some distance. So we decided to make a simplified toilet on a part of the veranda. (Fig.3)

4) A table of a sunken KOTATSU-type (a leg warmer with a coverlet sunken into a part of the floor) and a toilet put in a sunken area of the floor.
Some of the people with very severe cerebral paralysis can move on the floor by crawling on all fours or turning over. Though they are unable to ride on a wheel chair by themselves, they can reach the destination on the same level of the floor.
So we remodeled a part of the room of the home for them. Both aids are sunken into the floor so that they let their legs down and sit by themselves and accomplish their purpose with a little support.

5) Aids to keep a posture
One of the important cares for severe disabled who lies in bed almost all day is to avoid to stay still in the same position. The biggest trouble is the position remaining lain on his back for many hours. That causes deformity contracture and disturbs the growth of oral function and sometimes weakens heart and lung function. As a matter of fact, that might be the cause of mental returdation and in case of old people mental decline.
We tried to find the most suitable posture by his ability and object, and then made several aids named "posture-keeper". Postures are of sitting, lying on one side, lying on the stomach, kneeling and standing. When we make an aid, we choose one from them judging from his way of life and physical therapeutec viewpoint.

2. Subjects of individually made aids for the future

1) Relation of aids individually made and those made in other ways
If you define a technical aid as "an aid to reduce mental and physical disability", you find so many things of the kind like cars, elevators, escalators as means of movement. Recent home electric products like a full automatic washing machine, a dishwasher, a remote-control switch of a TV set, a video tape recorder and an air conditioner might be called technical aids in a wide sense. Personal computers and word-processors may be communication aids.
You might find some technical aids among general industrial products produced on a large scale (production unit: 1,000, 10,000) but most of the aids are developed especially for disabled and shown in a catalog. They are produced on a medium scale (production unit: 10, 100, 1,000).
In case of severer disability, it's more difficult to find a suitable aid among those on the market. As you see the examples shown above, people with severe disability have to order an aid individually.
Orthopaedic aids might be classified as technical aids in a wide sense, but they are supposed to make fitting to his physique, so they are made individually in principle. But not all of them are made individually. Common parts and materials are produced on a large or medium scale, and we make an aid by using some of them.
I think it effective to prepare the parts separately, the parts individually made and those mass produced. An electric wheel chair for the severest disabled, for instance, will be completed with standardized wheels and various parts for controllers adding a posture-keeper to them. In this way you can get quolitative and economical improvement.

2) Material, Technique, Safety
New materials for individually made aids have been imported lately. We are required to adapt them to those who use, and needless to say to make good use of them. When you make a chair, for example, you must know the best position of the user and the best way to form that position. You might think it a therapist and a doctor's role, but I believe makers of personal aids also need to get fundamental knowledge and technique. Suppose that a therapist or a mother of a dsabled child makes his chair with cardboard boxes. When these two elements are well-balanced, an aid individually made is really useful for the necessary situation.
Wood, a familiar material, used much for furniture, might be called a very human material with soft touch. It's easy to treat and work upon with simple tools, so it is one of the best materials to make individual aids. But at the same time it has the limit in durability and safety. You need much time to treat on the surface by painting and it will be a weak point of wood, too.
"Erector System" has been practically used more for individually made aids recently. It is composed of pipes of 28 mm. outside diameter from steel pipes of 0.7 mm. thick coated with AAS recin which is excellent in strength and weather-proof, and many kinds of joint parts molded from the same resin and other related metal parts. Cut a pipe at a certain length, put it into a joint and pour an adhesive into a chink between a pipe and a joint, then you can get a frame with definite strength more easily. But never forget careful examination of a plan to prevent troubles in safety. You have to pay more attention when you use the system for a handrail or other frames which requires much strength.
"Right material in the right place", I believe it important to make individual aids. To comply various requests we must always be ready to use many kinds of materials and parts technically and materially. As a matter of fact we are not satisfied with economical conditions. I wish we had a public technical aid center in our country like one in Sweden.
My future plan is that I will visit wherever I am required, with necessary materials, parts and instruments loaded on a car, and make chairs, toilets, playthings and to remodel a room with handrails or to add stools.

3) Holding information in common and training makers of individual aids
This new work started at "DEKU KOHBOH" have prevailed to 32 places in all over the country and 36 including those in colleges and welfare facilities. Each of them usually works for itself in its own area, and once a year they all meet together in order to hold a conference for exchanging information and making a study.
As an excellent maker of individual aids, one is required to settle various problems at a necessary situation. He will learn more as he has more experience of field work. I don't mean the training school is not necessary at all. A public training school for makers of individual aids including orthopaedic aids makers is earnestly desired to be established as soon as possible.

3. Conclusion
Skill to make individual aids is helpful for only a single disabled person who is more difficult to be classified than any other disabled. By using this skill you can respond any small requirement of work and remodel of the aids easily. You can start to make aids whenever you want, wherever on the earth without any special, big scale of production equipment.
To the development of the field of this work hereafter, as many people as possible are needed to work together in cooperation.

THE POTENTIAL OF EXISTING TECHNOLOGY TO PROVIDE SOLUTIONS IN REHABILITATION MEDICINE

K. BOSE and J.C.H. GOH
Department of Orthopaedic Surgery, National University Hospital, Singapore

Technological advances are now capable of providing solutions to many of the intractable problems that we have faced in the rehabilitation of the disabled in the past. Today with the progress of control engineering, computer technology, materials and manufacturing we are capable of rehabilitating even the very severely disabled in a more comprehensive manner than ever before. Though on one hand there is an enormous impact of technology in the rehabilitation of the disabled and yet many of our clients are not receiving the appropriate help they need.
The objective of this paper is to focus our attention on how to use the existing technology to reduce the disability so that the disabled person can have an enjoyable, independent and productive life. It is important for us to look into the technological solutions from the consumers point of view. According to the level of technological help required we can divide the consumers into three broad groups.
Group I: Most people seeking technical aids fall into this category. They basically need information about what is available, and where to get both the information and the device. They tend not to be connected to the "rehabilitation system", nor have they any ongoing need to be. If there were a consumers report type publication which could lay out the device features, comment on each and let the consumers decide the trade it would adequately meet this group's need.
Because rehabilitation professionals rarely interact with this group, we tend to forget they exist but this is a large expanding group and deserves more attention than have been paid in the past. Their equipment needs are often simple and straight forward and is usually within the capability of most of us.
Group II: This group generally uses standard rehabilitation related products, they may use the "rehabilitation system" from time to time, and they generally have an idea of where to go to get the equipment they need. These are usually the patients with spinal cord injuries or amputees whose medical rehabilitation problems can also be defined.
Group III: The third category involved the fewest number of customers, but the greatest amount of intervention. These clients tend to be more severely disabled, have more complicated equipment needs, and have a larger number of service systems and professional involvement. They generally require a total team approach, thorough evaluation, customized fabricated equipment and training in the use of devices. These cases are often expensive, time consuming and frustrating for everyone involved but they can be very rewarding.
Group II and Group III clients can benefit a great deal from our modern technology.
As for the Group II clients many commercial companies are producing equipment which can significantly improve the communication ability, help in the activities of daily living and use innovative methods to overcome the problems of mobility and ambulation.
As for the Group III clients many of the equipments available in the market are not suitable. They either require modification of what is available commercially or they may require individualized custom made appliances. To cater for the need of this group we require some inhouse facilities. This is often based in a tertiary institution with close links with the Department of Rehabilitation Medicine. The management of this group is unlikely to be cost effective from a commercial stand point but the technological advances can make a significant difference to this group and some provision must be made for them.
Technological advances in Rehabilitation Medicine is mind boggling. These advances are in the field of control and microprocessor engieering, computer technology, optics, mechanical engineering design and finally materials and manufacturing industry. It is difficult for me to enumerate all that is available or possible nor I feel it is necessary. What is important is that we look into the technology from the clients point of view.
Basic needs of our clients are : (1) Communication; (2) Activities of daily living; (3) Mobility; (4) Ambulation; and it is important for the rehabilitation team to cater for the individual clients need.
(1) COMMUNICATION: For a large number of individuals with disabilities, the most serious barrier to any meaningful opportunity for education, personal development, creativity or employment is the lack of an effective means of communication.
Technologies capable of solving some of the communication problems are now available and a large number of communication aids ranging from the relatively simple (eg. symbol communication board, flash cards, etc) to the extremely sophisticated (eg. Blissymbolic electronic communication board, Canon communicator, Sharp Memowriter, Mini-Comm, etc) have been developed and are being used.
With the advances in microcomputer technology and its relatively lower production cost, the microcomputer has become more accessible to many of our clients. The microcomputer is flexible and can be adapted to the needs of a non-verbal clients. With associated software, the computer can be used for a wide variety of purpose by education, recreation and employment.
The microcomputer can simulate all the functions of a standard communication aid. In addition, it has the flexibility in accepting manydifferent inputs (eg. keyboards, single/multiple switches, voice recognition units, optoelectronic units), a variety of storage devices (eg. diskette, magnetic tapes, video disks) and many different output devices (eg. printers, speech synthesizers, modems). Thus the microcomputer technology has filled in an important gap in our ability to communicate and inhouse facility is necessary to cater for the need of individual client.
(2) ACTIVITIES OF DAILY LIVING: There are many devices that assist individuals who are physically disabled, to live as normal and as independent as possible. These devices range from those used in feeding, toiletry and reading to those used in kitchen, recreation and transportation. Most of the devices are relatively simple but ingenuiously designed, either mechanically or in the electrical/electronic circuitry or both.
For those individuals who are severely disabled and especially those who are bedridden, environmental systems are available which will allow them to have a reasonable quality of life. These systems can help the disabled individual to remotely turn on the television, draw curtains and switch on the fan, cooker or lights etc. A major problem for severely disabled persons who are living alone is an effective and economical means to ensure their safety and ability to summon for help when required. Microprocessor-controlled systems have been developed to control locks and windows in the homes and to provide emergency call signals for non-verbal individuals. Other areas that has benefitted from the technological advancement are in the development of control systems for upper limb movement, ambulation and incontinence etc.
(3) MOBILITY: The pursuit of an independent living lifestyle for the disabled must ultimately satisfies the individuals need to be mobile. The non-ambulatory persons require some form of mobility devices; for children, there are the caster cart, saddle walker, prone tricyle or swivel walker which the child can use to propel themselves around. For the severely disabled, the MacLaren buggy has been found to be very effective and wheelchairs (either manual or powered) are availabled for both children and adults. Power wheelchair design has received extensive attention in recent times. Different types of control has been developed eg. single/multiple switches, joystick, tongue switch, head or chin switch, and voice control. Batteries has been designed to last longer and more powerful. Modifications can also be made to allow wheelchair to climb staircases. Due to high cost of a power wheelchair, low cost motor units have been developed, which can be fitted onto a manual wheelchair to convert it into a motorised one.
Associated with wheelchair a special seat design is often necessary. When an individual is required to sit for a long period of time, the seat has to be designed to minimise risk of pressure sore, maximise functional capabilities, minimise progressive deformity and maximise comfort. These seats are usually custom made to each patient's requirement.
(4) AMBULATION: The use of walking aids eg. crutches, rolator, walking stick are still very much required in rehabilitation. No major design improvements have been made in these type of aids, except the use of stronger and lighter materials in their construction. The most significant advancement in the field of prosthetic and orthotics is the use of current CAD-CAM technology in the production of prostheses and orthoses. This not only cuts down the delivery time but also improves the quality of fit. Another major development is in the field of functional electrical stimulation for paraplegic patients, using control engineering and artificial intelligence, this group of patient may be able to walk again.
The advances in technology have also extended to the assessment of walking pattern. Gait analysis system utilising optoelectronics and computer system. (such as the Vicon, Selspot or Coda system) have made tremendous progress in providing objective evaluation of gait and thus monitoring the effectiveness of the rehabilitation regime. Normative data obtained from such systems forms the basis in the design, development and testing of prosthetic and orthotic devices.
Therefore to exploit the potentials of existing technology in solving problems in rehabilitation medicine, it is imperative that we have an integrated multidisciplinary approach based on the specific requirements and keeping in mind our clients' needs. This will set us in good foundation to fully harness the rapidly advancing technology and substantially improve the rehabilitation of the disabled.

REFERENCES

1. Bleck E. Rehabilitation engineering services for severely physically handicapped children and adults. In : Current Practice in Orthopaedic Surgery, 223-244.
2. Engineering for people with disabilities - Breaking down communication barriers. In : Waisman Center Interactions, January 1984, University of Wisconsin System Board of Regents.
3. Parnes P, Lee K. Use of the apple microcomputer as a communication prosthesis - application with the non-speaking physically handicapped population. IEEE, 1982, 7, 39-44.
4. Proceedings of the 2nd International Conference on Rehabilitation Engineering, June 1984, Ottawa, Canada.
5. Vanderheiden G. Computers can play a dual role for disabled individuals. Byte, September 1982, 1-8.
6. Bose, K and Goh, J C H : Applied Research in Orthopaedic Surgery. Applied Research and Its Management, pp 184-198. Published by the Faculty of Science, National University of Singapore, 1986.
7. Bose, K and Goh, J C H : Impact of objective motion analysis in the practice of orthopaedic surgery. Journal of the Western Pacific Orthopaedic Association, Vol XXIII, No 2, pp 1-13, December 1986.
8. Bose, K : Current state of biomedical engineering in Singapore. Keynote Address, Proceedings of the Fourth Symposium on Biomedical Engineering, Singapore, pp 1 - 5, June 1987.

DESIGN AND USE OF APPROPRIATE TECHNOLOGY

TONU KARU
Institute of Chemical Physics and Biophysics, Tallinn, Estonia, U.S.S.R.

Since the early 80's major changes for the integration of disabled population can be followed. The information, collected and disseminated by the UN, "Rehabilitation International" and other agencies have served as invaluable sources of new ideas and approaches. Soviet specialists have had many good results in this field, which might be of interest to the world community of rehabilitation. The flow of information has not been permanebt because of the lack of formal contacts between Soviet specialists and international organizations for rehabilitation.

New legislative acts of central and local governments can supply extra funding for future research and development. That serves as a basis for developing appropriate technology for independent living. The term "appropriate" varies upon the users skills and motivation.

New organizations of disabled people have started small co-operative enterprises for producing technical aids. The first information and demonstration centre of technical aids in the Soviet Union was found in Tallinn, Estonia in 1982. ICTA has played a very important role in having it updated.

Disabled people have created numerous aids themselves. The task of specialists and volunteers is to help to commercialise the ideas, to motivate production and supply training and maintenance, if needed. The long-term experience of occupational therapists of developed countries has to be introduced.

The Estonian Academy of Science has initiated an applied research program to develop appropriate technology for independent living. As a result of teamwork together with architects, the first legislative act of barrier-free design of public buildings was introduced in Estonia in 1982. It serves as a basis for all-union approach.

The skills of young students - designers and engineers are used to get new appropriate ideas. The mass media plays very important role in introducing the new approaches. The link of United Towns Organization has served well for international joint seminars and exhibitions.

There are fine prospects for using the results of fundamental research for designing of new appropriate technical aids (speech synthesis, special software, new materials, biotechnology, hightemperature superconductivity, etc.). International co-operation and co-ordination of activities are essentially needed for reaching appropriate cost-effective solutions.

The 11th World Congress of the International Federation of Automatic Control will be held in Tallinn in August 1990. It would serve as one of the forums to share ideas about appropriate technology.

Considering the economic, technical and emotional realities, priority is being given to appropriate aids for handicapped children. The Soviet Children Fund acts as a source of initiatives and founding.

PRODUCING LOW-COST HIGH-QUALITY WHEELCHAIRS IN AFRICA

R. HOTCHKISS
Appropriate Technology International, U.S.A.

PRODUCING LOW-COST, HIGH-QUALITY WHEELCHAIRS IN AFRICA

A worldwide team of wheelchair riders, designers, entrepeneurs, and engineers has been working for eight years to make low-cost, rugged, state-of-the-art wheelchairs available in developing countries, with specific emphasis and examples from Africa. A lightweight sports chair has been designed, and 20 groups in Latin America, Asia and Africa have begun manufacture. Sponsored initially by Appropriate Technology International in Washington, D.C., the work is now being continued by Appropriate Technology for Independent Living, a project located in California, with the help of ICTA, Partners of the Americas, and other groups.

THE NEED FOR WHEELCHAIRS IN AFRICA

In Third World countries, most disabled people who need a wheelchair simply don't have one. In Africa there may well be 3,000,000 individuals who need, but don't have, a wheelchair. The few chairs in use tend to be heavy and are too wide to fit through narrow doorways. These chairs are often in need of repairs, requiring parts that cannot be found locally. Of course, high cost is the reason most people don't have a chair. A wheelchair at current prices is out of reach both of most disabled people and of the social programs of most Third World governments.

As a disabled person myself, I began working on wheelchair design because I wanted a better wheelchair, almost regardless of the cost. This project has been quite an education for me, as it has become clear how much the high cost of a good wheelchair must be reduced before most of the world's disabled people will be able to own one.

New wheelchair manufacturers are spring up throughout the developing world; probably well over 100 have begun operations in the past five years. Most of their chairs, unfortunately, have been derived from the heavy, inflexible models popular in the West from the 1940's to the early 1980's. All of these manufacturers so far have been anxious to gain and employ new and better designs and manufacturing techniques. Therefore our first goal has been to create a network for the free flow of information between wheelchair builders throughout the world.

In the West, wheelchair design has undergone radical change in the past few years. Serious contenders in wheelchair sports have demanded a sleek, low-weight type of chair, and some innovators designed and manufactured their own models when their needs weren't being met by the large manufacturers. As a result, the older manufacturers have had to race to keep up with their small competitors, and as a result many different types of lightweight models are now available. The lightweight aluminum models that many Westerners now ride are of interest to Third World manufacturers, but the cost of the high-tech tools and materials that are needed to make these chairs is far too high.

We have attempted to put as much high-tech wheelchair design as possible into a form that can be built in the Third World, and then to seek out expert mechanics who can adapt and improve our designs for manufacture of the chairs in each country. The result so far is a combination of ideas that is giving useful innovations back to the Western world. Already, some of the most promising wheelchair builders and programs are in Africa. Their progress and problems are illustrative of some of the challenges for this continent.

MORE THAN A TECHNICAL PROBLEM

Even when good low-cost wheelchairs have become available, very few people in most countries have been able to buy them. Because there are few government programs to assist in the re-integration of disabled people, most of our customers have been from the wealthier families. The Disability Rights movement is gaining significant political strength in some countries, and change is coming gradually in eradicating education and employment discrimination. But lacking the most basic transportation, many disabled people are still left out.

India may demonstrate that change is more possible - and practical - than we had thought. The Indian government has provided hand powered tricycles - heavy duty outdoor models - to tens of thousands of its citizens. The Government is ready and willing to provide wheelchairs, we have been told, provided that good, dependable and usable chairs can be made for close to the $70 price of a tricycle. If this chair can be made - and it appears possible - India's mobility- disabled population may enjoy the biggest and fastest revolution in their lifestyle that the world has ever seen.

THE EVOLUTION OF THE TORBELLINO

Beginning with the mechanics at a wheelchair shop established by a new organization of disabled people in Managua, Nicaragua in 1980, the process of working collaboratively with wheelchair riders and designers in Third World countries was launched. By starting from scratch in building our first chairs, we quickly learned that the parts relied on by U.S. wheelchair manufacturers were not available, and the production techniques common in the U.S. were not useful. Because of difficulties in stockpiling large amounts of parts, chairs had to be built in small batches instead of in serial production. With such short production runs, our jigs and fixtures had to be designed for fast setup and disassembly.

Imported parts are not designed into our chair because of their high cost. Footplates, front wheels, caster forks and hubs all must be designed so that they can be made locally by a blacksmith. In order to withstand the stresses of heavy use on rough roads and because replacement parts may be difficult to obtain, the chairs must be as dependable and durable as possible. All the points where chairs normally fail have been analyzed, redesigned, subjected to destructive testing, and redesigned again until breakdown in the field has become a rare occurrance.

The axles on the chairs had to be stronger than the bicycle axles that are usually used for Third World wheelchairs; we decided upon larger 5/8" bolts and redesigned the hub of the wheel to fit this axle. In order to achieve our goal of low maintenance, we chose some more expensive parts such as precision sealed bearings. Over time, the fact that they cost more than unsealed bearings will be compensated by their long life without adjustment, cleaning or oiling.

Some design factors are not merely technical. Low-cost, efficient chairs must also appeal to the eye just as much as the outdated, chrome-plated hospital style chair. They must also be easy to operate, compact enough to slip through narrow doorways, yet stable enough to take out onto rough terrain. They must also be easily maneuverable, as much at home on a basketball court as on village roads.

In particular, the chair had to be lighter than a customary wheelchair, since it would be pushed and lifted under difficult conditions. At first it seemed impossible to lighten the chair while switching from high-tech components to parts to be made from mild steel by a blacksmith. After reshaping the frame to reduce the stresses on it and combining the functions of several structural parts, our chair eventually weighed 25% less than a customary chair. The current weight is 35 lbs. (16 kg.) when made of mild steel, and 26 lbs. (12 kg.) when made of chromoly tubing with aluminum wheelrims.

We have chosen balloon tires for the rear of the chair and wide wheels for the front so that the chair can travel over soft ground. The armrests follow the curve of the wheels, and the footrests fold close to the frame of the chair to allow the rider as easy a transfer into and out of the wheelchair as possible.

The final product of years of collaborative inventing and design work is called "El Torbellino" (in English, the Whirlwind). Currently close to over 80 mechanics have been trained to make it, and efforts to build the chair are underway at 20 workshops in 12 countries. We have made contact with well over 100 other wheelchair builders, and have shared technology with all of them.

The design of the Torbellino has been made available in a manual available for U.S. $15.00 through:
Appropriate Technology International 1331 H St. N.W. Washington, D.C. 20005 U.S.A.

A PROJECT TO DESIGN A HEARING AID FOR DEVELOPING COUNTRIES

O. BENTZEN
Danhearing, Hobro A/S, Hobro, Denmark

The Concept of "Health for All by the Year 2000" and the mounting of global programs against blindness and some aspects of orthopedic handicaps it is clear that the state is now set, when systematic action would be possible against deafness on the global scala where the estimated population, the year 2000, is 6.000 million people.
In the "World Program of Action concerning the Disabled" which has been adopted by the UN Assembly as the central strategy document for the decade of action following the International Year of the Disabled Persons, 1981, it is estimated to be 450 millions disabled in the world. 80 per cent of them live in less developed countries, mostly the poorest communities of Asia, Africa and Latin America, where UNICEF estimated 30 per cent are children.

WHO 1980 defines the hearing handicapped person as a person unable to comprehend normal speech, persons who belong either to:

Threshold Carhart = TC: The average threshold for pure tones of 500, 1000 and 2000 Hz, Bentzen (1984).

The oto-audiological treatment:

Is individual hearing aids which is unable to prevent hearing impairment or deafness, but able to prevent the development of deaf-mutism. The deaf child is with a hearing aid on the right and on the left ear able to hear his own voice and the sound of music in his mother tounge, words, sentencies spoken to him by his parents, members of the family, school-fellows, teachers, in short all people he needs to communicate with from the very start of his life.
We must remember that binaural hearing loss must be treated with aids stimulizing the right as well as the left side of our hearing organ. With one aid we listen, with two aids we hear.

As consultant to deaf children since 1953 in Denmark, Yugoslavia, Egypt, India and Sudan, I have seen and heard the acoustic effect of hearing aids in deaf children and followed the development of their ability to speak. In a big school for deaf in Mysore, India, we introduced the treatment with binaural body-aids to 110 deaf children. A few weeks later their school-fellows, in the section for the blind children, complained of all the noise produced by the deaf pupils so as voices, sing-songs and the teachers of the deaf spoken instruction and education.

The demand on the hearing aids.

The development of modern acoustics resulting in more and more sophisticated programs of hearing aids from: body-aids to hearing spectacles to micro-aids placed in the external earcanal has been a benefit for persons with moderate hearing loss and persons able to pay the increasing price for smaller and smaller aids.
This development in acoustics has not been focused on the partial and profoundly deaf and not on low-cost aids.
Shah (1980) refers to his examination on "Hearing Aid Dispensing in India" to illustrate the needs of hearing aids in a population of 670 million people. This is nearly one tenth of the estimated population in the world the year 2000 of 6.000 million people.
The National Sample Survey in India shows the incidence of irreversible deafness (mainly congenital or acquired in early childhood) to be 124 per 100.000 population or 0.124 per cent given 700.000 deaf children in India, 1980.
Among them only 25.000 are attending schools for the deaf where only 13.000 were using hearing aids. 30 million adults need hearing aids.

A Project to design a hearing aid specially for the developing countries.

We have developed our hearing aid DANHEAR 2000 as a:

• mass produced low-cost hearing aid
• double hearing aid with a built-in microphone and two separate output amplifiers
• sealed in a heavy-duty design case, placed on the user's chest fixated by straps or a spring clip
• controlled with an "oversized" volumen control for obviating control problems for elderly or handicapped persons having dexterity problems
• powered with two standard (1.5 Volt) batteries, e.g. Penlight with a lifetime = minimum 120-150 hours
• with technical specifications:
  Frequency range: 250-3500 Hz acc. HAIC
  Gain: 54 dB acc. HAIC 500, 1000, 2000 Hz
  Maximum output: 120 dB re 20 uPa acc. HAIC
  Maximum OSPL 90: less than 128 sB re 20 uPa.
• fit out with two standard earphones connectors.

DANHEAR 2000 is apart from the replacement of earphones and/or cords not intended for repair as all the electronic components sealed in plastic for optimum protection against sand, dust and corrosion by the high humidity in the climate of many developing countries.

References

(1) Bentzen, 0. Global Audiology International Congress of Audiology. Santa Barbara, California 1984.
(2) Shah, V. Hearing Aid Dispensing in India. International Hearing Aid Seminar. San Diego, California, 1980.

Title:
16th World Congress of Rehabilitation International No.8 P.319-P.375

Publisher:
The Organizing Committee of 16th World Congress of Rehabilitation International

Month,Year of Publication:
Jun,1989

To access/retrieve this document:
Japanese Society for Rehabilitation of Persons with Disabilities
1-22-1, Toyama, Shinjuku-ku, Tokyo 162-0052, Japan
Phone:03-5273-0601 Fax:03-5273-1523