PLENARY SESSIONS

<KEYNOTE ADDRESSES>

REALISTIC APPROACHES - LOOKING AHEAD TOWARDS COMPREHENSIVE REHABILITATION

REHABILITATION AS CONCEIVED FROM LITERATURE

KENZABURO OHE
Writer,Japan

It is indeed an honour to be addressing the 16th World Congress of Rehabilitation International. I must frankly admit that when I was invited to speak I was at a loss. I realized that I was an author and no specialist on rehabilitation by any means. However,at the same time I am the father of a disabled child and am deeply concerned about rehabilitation. It is as a result of having found myself between the horns of a dilemma that I stand before you here today.

Twenty-five years ago my first son was born mentally retarded. This was an accident. But I must admit also that since that time,the main theme and subject of my writing has been how to have my family live together and fully include our handicapped child.

I must also concede that the concepts I bear in my mind regarding society and the world at large,together with concepts which transcend day to day realities,have all been formulated and based upon my experiences of living with a disabled son.

What our family found most necessary in order to live with and interact with our son,was - particularly when he was an infant - to read what was going on in his mind. Especially,we didn't want to restrain him but rather liberate him.

In my son's case he showed no interest in talking,even after the usual ageone begins doing so. We didn't know if there was anything particularly the matter with his hearing.

Yet,it seemed to me that my son was interested in listening to recordings of bird-songs. Thus I arranged that his nursery room contain a recording of bird-songs,in which each particular bird was named after singing. After some time had elapsed,we went together into the mountains to spend a night in a cabin. When the birds sang,my son suddenly called out the bird's name! From that day on I could mimic a bird-song,and he would respond by telling me which dird it was. Thus,a very basic method of communication was initiated.

How does one attempt to interpret the words which might exist beyond a child's silence? How does one go about using one's imagination to fathom the inner processes of a child with mental retardation? It was something akin to attempting to express oneself in literature - an act of reaching into the depths and reading deeply into the meaning of the text. How does one go about reading a text which is subtle,difficult to grasp in meaning.... which seems to deny any and all attempts to fathom it? How does one exercise imagination in delving into the innermost reaches?

How can one express the life of one's own disabled son as the text of a novel? In going through real situations and attempting to express them to all of our family - including our disabled son - I experienced a twofold literary task. In other words,this accident of having a disabled child born to me became my lifetime's theme as a writer.

To write a novel about this child it required developing such a model of his complete individuality,which had to be expressed both completely,and also in concrete terms. The model needed to include not only the handicapped child himself,but also his family,the society and the entire world around him. I have continued to write novels in this manner,and in the process of forming a model by words I have observed there is a set pattern.

Professor Satoshi Ueda personally invited me to attend and speak at this Congress. In his book "Observations of Rehabilitation - Reinstatement of the Basic Human Rights of the Handicapped",he formulated a model of the process involved in a disabled person accepting their disability. I note the manner in which he has achieved this ties in with the literary model I have attempted through my novel-writing.

A person may become impaired with a handicap through some accident. A "Period of Shock" ensues in which he undergoes complete lack of concern and a state of depersonalization. This is followed by a "Period of Denial",which is a psychological defense mechanism that denies any disease or handicap. There then follows a "Period of Confusion" during which the impossibility of cure can no longer be denied. This is a period of bitterness,anguish,resentment, sorrow and dejection. However,the disabled person finally awakens to their own responsibility,breaks away from dependence upon others and attempts to establish their own set of values. This is the "Period of Solution-Seeking", which is then followed by a "Period of Acceptance" in which the disabled person accepts their disability as part of their personality and identifies the new role they can play in family and social life.

In the novel,and the development of my son's life,the above five periods were clearly experienced. Yet,in this particular situation of someone who is mentally retarded,it was not he but rather us - members of the family - who went through these periods from shock to eventual acceptance. The handicapped person and his family members went through the periods of =shock","denial" and "confusion" experiencing pain and hardships. From there,it became a question of how to proceed on to the "solution-seeking" and "acceptance" periods. It was only when these stages had been concluded that the novel was finally concluded. In fact,the novel is only complete when all the family - including the disabled member - comes to positively accept all of themselves and their situation.

I am certain that this is clear to those who have been exposed to the actual process of disabled peoples' rehabilitation.However,I should like to express my thoughts based upon my personal experiences and those of my family.

We found that the five stages mentioned above don't necessarily follow in sequence one after another.Furthermore,what we had considered as progression onto the"period of acceptance"turned out to be only a provisional transition, and one which had to be repeated several times over.This is the conclusion I've reached through expressing our experiences in novels and recreating them in word-form.

In thinking over the novel and it's expression,I recognize the importance of the disabled person and their family being able to live through and share together their feelings of anguish and hardship,as the various periods of "shock","denial"and"confusion"are experienced.Without such hardships, acceptance will never be reached....this is all part of being a human being.

In thinking this over,I began to realise that these five periods describe not only the lives of a handicapped child and their family,but that it is the form of all novels in general,and occurs at a universal level.For example, in "War and Peace",how did Pierre and Nastasia go through their periods of "shock',"denial"and"confusion",through the miseries of a major war,to finally arrive at"acceptance"following a"period of solution-seeking"?

After undergoing major harrowing experiences,Pierre eventually married Nastasia in the post-war society of St.Petersburg,and built up a family life. Pierre awoke to the role he had to play and the life he had to live for.I am tempted to say that the model is one of positively accepting the handicap, together with the soul and actions taken by the handicapped person who accepted them.

It can be said that the process by which a disabled person arrives at acceptance of their handicap is univeral amongst all mankind.The impact and importance of the periods of "shock","denial" and "confusion" is something that is vital to generate the power and strength needed to arrive at the "period of acceptance".Perhaps the following example will make this clearer: Without the major suffering brought on by the Napoleonic War,the post-war personalities and characters of Nastasia and Pierre would never have been forged. For Tolstoy,and for us readers,the first half of these two peoples' lifetimes - filled as they were with confusion and hardship - indeed formed the nucleus of this piece of literature. It was through these pains that the "Period of acceptance",and the qualities of drive,integrity and richness of human nature,were created.

I have been active as an intellectual living in post-war Japan.The concept that forms the foundation for my activities is something like the following: What is the backbone - the basic concept - embraced by Japanese people in the post-war era? In the process of modernizing the nation since the Meiji Restoration,the Japanese stumbled into a World War,caused major catastrophies in the Asiatic regions,and experienced the atomic-bombing of Hiroshima and Nagasaki,which led onto defeat.The same Japanese nation bore also the responsibility of post-war reconstruction.

Wouldn't it be appropriate to regard Japan as a nation,and the Japanese as a race,that had stumbled into a major war and inflicted themselves with a severe handicap? Also that they stood in need of awaking to the fact that they had indeed become handicapped? The defeat brought the bitter taste of "shock","denial" and "confusion" upon us....and the ten years - at least - that followed the war were undeniably a period of "solution-solving".

And now,after the passing of forty years,has Japan and the Japanese people,after having gained economic prosperity,truly reached the threshold of their"period of acceptance"? After having inflicted serious wounds upon themselves,have they accepted such injuries and achieved a change in their value-systems? Have they prepared themselves to play a peaceful and constructive role in Asia and the world? After gaining our economic strength, are we indeed living up to our responsibilities?

What I can proudly point to at the moment is the fact that I recognize in my son,although disabled,a character that has the qualities of being decent, humane, broad-minded, humourous and trustworthy.Also,by recognizing such characteristics and sharing together with him,all of our family experience the influence of his qualities in our own lives.
Apart from personal contacts and involvement with my son,I have come to know many other disabled people,their families,and others who have devoted their time and effort toward rehabilitation.All of these people have experienced suffering in one way or another.The handicapped person reaching the "period of acceptance" has the marks of hardship deeply impressed into them.So do their family members and all those involved in their rehabilitation situation.And with all of these people,I have been led to believe that their one universal characteristic is that they are all decent people.

Regrettably,I don't have the time to furnish supporting evidence of these facts,but I am sure that I am talking about them to people who would understand most readily.People who have overcome major adversity and hardship,family members living together through suffering,and those supporting rehabilitation efforts - this is indeed the image of decent people. I believe they are the ones who will effect the ties between Japan and the world,and it is there that the quest for a model of a more desireable person should be conducted.

FUTURE REALITIES FOR THE CHILDREN OF THE WORLD

DISABILITY PREVENTION AND REHABILITATION

V.RAMALINGASWAMI
Special Advisor to the Executive Director,UNICEF

It is a rare honour to be making this presentation in place of Mr.James P.Grant before this 16th World Congress of Rehabilitation International.The report of Rehabilitation International in 1980 to UNICEF had a seminal value in developing the current three-pronged UNICEF policy on childhood disability - prevention,early intervention and family and community support. We have just crossed the midpoint of the United Nations Decade of Disabled Persons, 1983-1992,and a United Nations global meeting of experts in August last year made a series of recommendations on the implementation of the World Programme of Action.

Prevention of Childhood Disability and Primary Health Care

This Congress meets at a time when human ability to deal with human disability on a global collective basis has never been more promising than now.Much of the disability in the developing world is preventable; much of the disability that has already taken place is correctable.The technology for prevention and correction is available and improving. A great human opportunity awaits us. There is better understanding of the complex causality of disability. The slow yet enlarging application of primary health care since Alma Ata (1978) is making a contribution; several components of primary health care play the role of primary prevention - immunization, growth promotion, promotion of weaning foods and breastfeeding. Others such as oral rehydration and control of endemic disease, e.g., tuberculosis and leprosy, provide secondary and tertiary prevention. Early recognition of childhood disability and early intervention can reduce disruption of developmental processes and halt the relentless escalation of impairment to disability and to handicap.

Communicable Diseases

Immunization is breaking the dangerous disability-producing synergism between infection and malnutrition. Immunization services which used to reach less than 5% of children in the developing world a decade ago, now reach more than half of the world's children in their first year of life with three doses of polio and three doses of DPT vaccines (Henderson 1988). The Expanded Programme of Immunization (EPI) has caught the imagination of governments and the public. So impressive is the outreach that other programmes making indifferent progress up to now, such as periodical administration of Vitamin A to children under five, and iodized oil injections, both of which are of profound importance in the prevention of childhood disability, will now piggyback on EPI. There are reasonable grounds to expect that poliomyelitis can be eliminated from the Americas, Europe and Western Pacific by 1995, and eliminated globally by 2000 A.D., when hopefully there will be no case of clinical poliomyelitis and no wild polio virus in the environment worldwide(Hinman et al 1987). Five years later, around 2005, if active surveillance reveals neither cases nor circulation of wild virus, the world may well be declared polio-free and hopefully no more polio vaccination may be required. A world free from polio and smallpox would be the gift of the 20th century to the 21st century.

Furthermore, 95% reduction in measles mortality and 90% reduction in measles morbidity, near elimination of neonatal tetanus, prevention of 3.5 million child deaths from diarrhoeal disease and of 1.5 million child deaths from acute lower respiratory infections annually by the year 2000 is considered feasible by the Task Force on Child Survival (Foege 1988).

Water and Sanitation

The International Drinking Water Supply and Sanitation Decade 1981-1990 will most certainly not achieve the goals it had set for itself, but an increasing number of countries are setting targets and national action committees are operating in 80 developing countries. There is increasing adoption of low-cost technologies suitable for village-level operation and maintenance. The change from the traditional purely mechanistic approach of public health engineering in respect of water supply and sanitation to an interdependent system of water, sanitation, nutrition, health education, control of diarrhoeal diseases, education and human resource development, is a welcome sign. The payoff in terms of control of guinea worm disease is already visible. Guinea worm disease (dracunculiasis) is often referred to as "the forgotten disease of the forgotten people". It is estimated to affect 5 to 15 million persons per year. About 140 million people are at risk in Africa, Asia and the Middle East. Because the disease does not kill but only incapacitates its victims, it has been neglected (Wash Field Report No. 240,1988). The burden it entails on agriculture and school attendance is beginning to be disclosed through recent researches. A small UNICEF study in one small area of Nigeria showed that among a population of 1.5 million people, $20 million worth of rice production is lost each year due to guinea worm. The elimination of guinea worm disease from the world is expected by 1995 (Hopkins 1988) - yet another gift of the 20th to the 21st century. The availability of clean water in adequate quantity will help in reducing the prevalence of trachoma, an important cause of blindness in developing countries.

River Blindness

A single dose of the drug, ivermectin, has been shown to be remarkably effective against one of the Third World's most devastating diseases, river blindness (onchocerciasis). River blindness afflicts about 30 million people, mostly in the tropical regions of Africa and Latin America. The disease causes relentless itching and blindness and has long been considered a major cause of disability and a significant factor in holding back development. Administration of this drug together with measures to control the breeding of the vector, the black fly, would lead to the eventual control of onchocerciasis. Advances in biomedical sciences stemming from the new biology promise the availability of new tools in the form of vaccines and drugs against tropical diseases, thus accelerating health development and disability control in the developing world.

Leprosy and Tuberculosis

Leprosy, a disfiguring and disabling disease par excellence, is on the agenda of the Congress. There are 12 million afflicted the world over. The deformities and disfigurements deprive patients of human dignity and love and lead to stigmatization and destitution. There are today signs of widespread acceptance of multidrug regimens of treatment. Patients are coming out of seclusion at an earlier stage and compliance is improving (Rao 1988). Leprosy need not be synonymous with deformity. The two can be dissociated by early detection and treatment before the threshold stage of nerve involvement. Prevention and control of physical impairment in leprosy is an aspect that is likely to be neglected in the mass public health approach of coverage and completion of treatment, a point to bear in mind (Max 1988).

The availability for several years now of effective multidrug chemotherapy against tuberculosis, the childhood forms of which are attended by serious disabling sequelae, has yet to lead to a substantial impact on tuberculosis in many developing countries, although even here there are signs of change. Shimao (1988) here in Japan described how effectively Japan brought its once considerable tuberculosis problem completely under control.

Malnutrition

Malnutrition is an all-pervasive disability. Although the ACC/SCN of the United Nations agencies in its first report of the world nutrition situation finds some evidence of improvement over the last twenty-five years (U.N. 1987), the problems that remain are formidable and regional disparities considerable. The most widespread of all is protein-energy malnutrition. It is a part of the wider problem of poverty and socio-economic development, and lies at the root of the developmental attrition of childhood so widespread in many parts of the developing world. Using weight for age as an index, 100 million children are malnourished in Asia, 20 million in Africa, and 10 million in Latin America. Nutritional blindness in children due to Vitamin A deficiency continues as a needless tragedy. Simple as the technology for its control looks, the problem of maintaining acceptable coverage of the most disadvantaged segments of society at each distribution cycle remains to be fully overcome. 500,000 cases occur annually of new active corneal lesions due to Vitamin A deficiency, and 6-7 million cases of non-corneal xerosis occur among pre-school children.

Much still remains to be done in the control of iodine deficiency. Recent evidence points to a wide spectrum of disabilities resulting from severe iodine deficiency, including goiter, cretinism characterized by mental deficiency, deaf-mutism and spastic diplegia and lesser degrees of neurological defect related to intra-uterine iodine deficiency, impaired mental function in children and adults, and widespread hearing disability. Iodinated salt and iodized oil have been shown in several situations to be effective in correcting iodine deficiency on a large scale (Hetzel 1987). Large populations, 600 million in Asia and 1 billion in the world, are at risk of iodine deficiency because they live in an iodine-deficient environment. There are more persons suffering from iodine deficiency in Southeast Asia, approximately 100 million with goiter and 18 million cretins and cretinoids, than in any other region of the world (Clugston et al 1987). Iodine is in short supply in the world. It is produced mainly in Japan, our host country. There is a great opportunity for our host country in collaboration with WHO and UNICEF to ensure adequate per capita consumption of iodine at the rate of 100-150 micrograms a day in deficient areas and get rid of this ancient scourge of mankind. May I express the hope that this Congress may prove to be a watershed in our efforts to eradicate this blot on society.

There is no indicator in human biology which tells us as much about the past events and the probable future trajectory of life as the weight of the infant at birth. It marks the start of life, extra-uterine life. The state of health and nutrition of the mother has a profound influence on the growth and development of the fetus during intra-uterine life. How marvelous it would be if each pregnancy grew out of an immaculate desire towards the offspring's good life! How can we create conditions for a good start in life for every newborn? The magnitude of the task awaiting us is evident from the rates for low birth weight - below 2.5 kg - which run at 31% of births for Middle South Asia, 14% for Africa, and 10% for Latin America.

The Safe Motherhood Initiative emanating from the Nairobi Conference last year through the provision of essential obstretic care and safe birth technologies in small district and rural hospitals, and measures to prevent the rising problem of accidents, are essential components in a strategy for prevention and rehabilitation of childhood disability. The most important advance is the realization that injuries have an epidemiology that can be described, and that they are no more likely to occur by chance than are diseases (Guyer and Gallagher 1985). The term "accident" with the connotation of fate or chance is being replaced by the term "injury". Children at risk can be identified and targetted for preventive strategies and a whole range of injury-related public policies, regulations and consumer safety laws can be enacted.

Rehabilitation

Prevention and rehabilitation go together. It is not a question of either/or. As in prevention, so in rehabilitation, there have been conceptual as well as practical advances. A most profound conceptual advance is the opportunity to reach larger numbers of disabled and achieve maximum coverage with essential rehabilitation through the development of community-based rehabilitation services within the framework of primary health care and other community services. This approach.will meet the essential needs of 70-80% of the disabled in the community, the remaining 20-30% has to be met at the referral levels (WHO 1987). Institution-based rehabilitation services are at present available to less than 3% of the disabled population in most developing countries. The tools for community-based rehabilitation services now exist. Several successful programmes have been developed; they have been introduced at least on a trial basis in 40 countries. Progress has been made in developing rapid, simple methods of assessing severe childhood disability. Developmental screening checklists are available. Child-to-child, parent-to-parent, the disabled themselves and their parents, community workers, primary school teachers, volunteers - these constitute a hierarchical force of great potency which can be mobilized. The needed appropriate technology is also available. How important it is to use the skills and knowledge of local people and maintain people's dignity is exemplified by the story of Pepe's crutches in David Werner's book Disabled Village Children (Werner 1987). The motto is how disabilities can contribute to our abilities and strengths. This Congress is dedicated to the concept of comprehensive rehabilitation, that means to the whole child. And consideration has to be given to what a child can do, cannot do and might be able to do. More value is placed on being human than on being normal.

Rehabilitation professionals, therapists, biomedical scientists have an important role to play in community-directed rehabilitation, by simplifying techniques, teaching local craftsmen, helping them to understand basic principles and concepts, facilitating self-directed learning, adapting therapies artfully to each child. It is not less science but science related to problem-solving within the social and economic and cultural context that is needed. Basic concepts in kinesiology, locomotion, gait, ergonomics need to be transferred, leading to the design of appliances within local resources and matching local habits and customs (Sethi 1987).

We are in the midst of a new revolution in materials/sciences. A vast range of new materials which have a great potential for developing simple new designs compatible with different lifestyles are now available

I have throughout this presentation used the word simple often. "How simple is simple?" asked the Urdu poet Mirza Ghalib of Delhi. He said ruefully, "Even man finds it difficult to be human."

References

REALISTIC APPROACHES:LOOKING AHEAD TOWARD COMPREHENSIVE REHABILITATION

O. GEIECKER
President of Rehabilitation International
Deputy Director General,Austrian workers'Compensation Board,Vienna,Austria

Today,at the opening of the 16th World Congress of Rehabilitation International,which will focus on "Realistic Approaches - Looking Ahead Towards Comprehensive Rehabilitation",we are at the beginning of a meeting at which we will strive to develop new successful ways for the rehabilitation of disabled persons and to formulate our future objectives even more explicitely than so far.

Our world organization is thus once again voicing the concerns of disabled persons and of all organizations interested in the field of rehabilitation. Rehabilitation International considers this World Congress an important contribution to the Decade of Disabled Persons proclaimed by the United Nations which is soon to end.
Today, at this very moment when I have the honour and the privilege to actively participate in the opening ceremony of the 16th World Congress and coming to the end of my term of office as President of Rehabilitation International, a very important event in my life comes to my mind, the moment when I had the opportunity to address the delegates to the 15th World Congress of RI in Lisbon as the newly elected President of Rehabilitation International and to present my views and ideas on the future activities of our world organization to them. At that time, one of our main objectives was to raise public awareness on the concerns of disabled persons and to provide disabled persons with equal opportunities and full participation in society. Therefore, the 15th World Congress with its general theme"Information,Awareness and Understanding for the Integration of Disabled Persons into Society"had set itself the task of dealing with the most pressing immediate problems and of finding ways to solve them. It is with some sentences from my address at the closing ceremony of the 15th World Congress that I would like to begin my statement about the general theme of the 16th World Congress.
I said:
- economic prosperity,high technology and legal regulations constitute an important basis for the realization of a better society that will offer its members equal opportunities for their social and mental development;but this society can only be realized if the sense for real solidarity and truly humanitarian attitudes is awakened in all people - the problems of disabled persons are very closely linked with the social,economic and cultural policies of all systems of society and, therefore, at first give the impression of being tremendously complex,but a closer look reveals that they actually can be reduced to a purely human problem - Man's problems are universal - regional and national borders must therefore not put any limits on the idea of rehabilitation -
And I finished,saying
- Our work in the field of rehabilitation can be compared with a big stream into which, on its long way from its origin to its destination many brooks are flowing,sometimes making the clear water cloudy in the process,but always making it more powerful -
and
- I am confident, that the creative spirit, the dynamic force and the experience of our members will allow them to make a significant progress with regards to solving these problems and that at the next World Congress in Tokyo we will be able to present you another successful report on Rehabilitation International's activities -
These ideas in some ways constitute the link between the 15th and the 16th World Congress of RI,and four years later,I am extremely pleased to note that many of the ideas I voiced have become realities and are reflected in the activities of Rehabilitation International and that the reports which will be presented to you during this World Congress will give you a picture of our successful work.As today the 16th World Congress of Rehabilitation International starts its deliberations and as we at the Congress will try to anticipate future developments and trends,right at the beginning of the meeting we have to ask ourselves how we should understand the general theme of this World Congress "Realistic Approaches - Looking Ahead Towards Comprehensive Rehabilitation"and which tasks are set to us by this general theme.
"Realistic Approaches" - this must certainly mean that, basing ourselves on the realities with which we are faced, we should find ways and define means which will bring us closer to our goal of a comprehensive rehabilitation.This does not mean that we should just put aside our dreams and our idealistic views which in the past have always been a source of inspiration for the successful development of our activities. It rather means that we should try to confront our hopes and ambitions with the existing realities and try to find ways to solve the resulting conflicts. You will therefore have to concern yourselves with the economic resources and future prospects of various regions, with demographic trends,with possibilities which scientific progress,especially in the medical and technological field,gives us,just as with climatic and geographic conditions and the influence of cultural,religious and traditional values on society. We all know that about 10% of the world population is disadvantaged in relation to the other members of society because of disabilities of various types.We also know that about three quarters of these disabled persons live in an environment in which sheer survival is the most pressing problem.Food, shelter, the preservation of the simplest family ties and social ties are some of the main problems of those persons apart from the necessity of finding ways of earning a living and of securing their bare existence. That under these circumstances our concept of a consistent health care and medical care,of an adequate education for young people and of an indepth vocational training might often seem a luxury one can only dream of,is easy to understand. I am speaking about the problems of those persons who do not live in industrialized countries. Things which for persons in industrialized countries have already become a reality will for a long time still remain unobtainable for many persons in non-industrialized countries.Just let us bear in mind that with the amount of money spent for a special wheelchair in an industrialized country, which in these countries is part of any normal rehabilitation programme, one could probably easily finance a simple rehabilitation programme or a vaccination campaign for a great number of persons in a non-industrialized country. Or let us look at the problems linked with the specialized staff necessary for the implementation of rehabilitation programmes. In industrialized countries, as a rule we will find both the staff and the necessary training facilities in sufficient number and variety. Non-industrialized countries which still need to develop their economic resources to survive will often lack both.
The possibilities and needs of non-industrialized countries in the area of rehabilitation will therefore clearly differ from those of industrialized countries.In this respect we also have to take into consideration that non-industrialized countries have to a major extent a very young population as a result of the rapidly growing population in the recent past. We should also remember that as a very positive factor in those countries the family,and very often still the extended family, is the nucleus of life of society. When malnutrition, insufficient health care and lacking or insufficient education and training facilities lead to a major increase of the various types of disabilities, it is in the first place the family which offers its disabled members protection and care. The measures to be taken in those countries will have to focus on eliminating the major problems but also very much on the preservation of the family and of its protective function for disabled persons.
In industrialized countries, the claims of disabled persons mostly concern improvements of social security benefits. Disabled persons ask for a secure existence for themselves and their families, for improvements in the area of health care and medical rehabilitation, as well as of housing. They demand equal opportunities in working life and social life. Apart from legal, administrative and organizational measures,they also ask for the use of modern technology to improve their daily life.In this respect,I would,as a reminder, also like to mention the long-standing claim for an elimination of those barriers which hinder disabled persons from easy access to facilities in the fields of education,culture,leisure and sports.In industrialized countries, the main themes of the World Programme of Action of the United Nations "full participation and equal opportunities" have found a strong echo and have to some extent already been realized.Apart from the clear advantages which the citizens of industrialized countries enjoy in comparison to citizens of non-industrialized countries,advantages which give them a definitive advance in the rehabilitation of disabled persons,there is one deficit which could become a focal problem in most industrialized countries.I am speaking about the progressive disintegration of the family as a center of common interests and social activities but also in its role of protecting family members from negative influences and dangers and of caring for them. The endeavours of governmental and non- governmental organizations to at least partly assume the role of the family seem necessary in view of the difficult situation we are faced with,but can in most cases only constitute an unsatisfactory replacement. Moreover,such measures bear the danger of unwillingly contributing to the disintegration of the family.
Due to the improvements of medical care but also to new life styles and working conditions,in most industrialized countries we nowadays observe a significant increase of the average life span and life expectancy.At the same time,the birth rate is decreasing and the number of families which only have one or at a maximum two children is steadily growing.We therefore can safely predict that the percentage of older and old persons in the general population will significantly increase in industrialized countries in the near future. Thus, the percentage of those persons whose physical capacities are to a certain extent reduced and whose health is impaired will increase.Because of this,the rehabilitation and care for older persons will gain more and more importance in industrialized countries;this also in view of the fact that the family, as I already explained,does not fulfil its traditional role anymore. We also have to face the fact that apart from the provision of the necessary care for old persons in adequate facilities,because of the increasing number of families in which both parents are working,we will have to create adequate facilities for caring for the younger generation - a role which in the traditional family was fulfilled by the members of the older generation.
Some difficulties which arise in industrialized countries could probably be avoided or significantly diminished if the traditional family still existed. As the solutions tried out until now only seldom found the undivided acceptance of all persons concerned,it could amongst others be also one of your tasks to consider this problem and to make proposals which could lead to an improvement of the situation.However,at this Congress we are set another task which is indicated in the general theme,because the words "Realistic Approaches" are followed by the sentence "Looking Ahead towards Comprehensive Rehabilitation". What does this task consist in?Were the goals we had set us in the past wrong? Was our work in the past insufficient? Should we find completely new ways of proceeding?
I believe that the answer to all these questions is quite simply "no". We can look back on many achievements in all areas of rehabilitation, achievements which partly encourage us to great hopes for the future. I am thinking, for instance, of the use of modern technology in different areas of rehabilitation, of the developments in the medical field and also of the application of new methods in education and training which allow us to find solutions in cases which until now had been considered hopeless. Why should we then abandon those successful methods of promoting the development of the various fields of rehabilitation and aim at a comprehensive rehabilitation? To answer this question, we first have to consider the significance of the term "comprehensive rehabilitation". Comprehensive rehabilitation means that the rehabilitation of a disabled person does not just consist in the provision of medical care, of education or vocational training or of individual measures which concern the disabled person's social life. The rehabilitation process can only be considered to have been successful if through the coordinated concurrence of all these measures, the optimum integration of the persons concerned into their social environment has been achieved and if these persons are seen as independent and self-responsible members of society.
The real problems do not arise from weak spots in our work so far, the real problems arise in connection with the timely perception of the trends in the future development of our society and in connection with the new appreciation of the importance of the individual for the community, respectively of the responsibility of the community towards the individual. This new appreciation of the individual as a part of society also encompasses the obligation for the individual to make the best possible use of the possibilities offered by society for personal development and as an individual to thus contribute to the well-being of society, so that the weaker members of society can also make use of the possibilities society offers. Originally, society only helped to secure the material basis of the existence of individuals and their families. Later, society also began to provide health care measures. All these measures were seen as mere care and prevention measures which the economically better-off part of society had to provide for the weaker and more needy members of society.
Some time ago no one thought that the persons which had to make use of such benefits would ever be able to significantly contribute to the progress and development of society.
Today, opinions are undergoing a fundamental change. Society nowadays is beginning to see disabled persons not only as a group at the outskirts of society which constantly needs the help and support of the rest of society, but as an important part of the community which under certain circumstances can contribute a lot to the well-being of society. Therefore, it must be the aim of comprehensive rehabilitation to put the disabled persons at the center of a complex system of activities, in order to promote the optimum development and improvement of physical and mental capacities and of an integration into society as independent and self-responsible members. For this purpose a number of measures need to be taken. Measures that concern as well the medical, the technical and scientific area as the organizational, administrative and social area. The impressive developments and successes in the recent past in the medical and technological field have to be combined with the new knowledge and possibilities in the educational and vocational field of rehabilitation and with respect of the new understanding of the role of men in society. For instance, gene technology as a new branch of science might allow the most spectacular improvements in the field of rehabilitation, if mankind will also live up to the great ethical responsibility which is inseparably linked with the use of this technology.
The concept of comprehensive rehabilitation has to find a permanent place in the views of society and to become an integrating part of the social security programs, of legislation and of education and training programs. Comprehensive rehabilitation is not only an organizational problem in the area of the rehabilitation of disabled persons,but most of all a socio-political problem which partly reflects the basic attitudes of the majority of a society and especially also the consciousness of the political leaders of this society about their responsibility concerning the humanitarian problems of the present.
There are many more things to mention,but I believe that the few examples I gave also show how the idea of a comprehensive rehabilitation can be achieved by an adequate selection of the various means at our disposal in the medical,technological and scientific area and by their joint use for achieving the highest level of rehabilitation for disabled persons.The situation is similar in the organizational and administrative and in the legal and social field.
But also with new concepts in the future we will have to continue working for the interests of disabled persons as a humanitarian concern above all national borders and racial,political or religious differences with human beings at the center of all our endeavours.Medicine,science,technology and organization should always serve mankind but we should not let ourselves be ruled by them.
Rehabilitation programmes,especially if they should comply with the exigencies set to us by the concept of a comprehensive rehabilitation,have to be established taking into consideration the needs of the clients and the economic and social environment.Important financial means or technical facilities do not by themselves guarantee the efficiency of a rehabilitation programme. Community-based rehabilitation programmes with very limited goals often have proved to be more effective than programmes which benefit from far greater financial support.If we consider the concept of comprehensive rehabilitation globally,then we have to admit also that problems which the non-industrialized countries are confronted with in the implementation of rehabilitation programmes could be solved if they disposed of more financial means,of better equipment and of trained personnel.
This means that the persons in these regions should be given the same possibilities for their lifes as persons in industrialized countries.The principles on which our concept of rehabilitation is based - namely equal opportunities and full participation - should also be applied to the problems of our world.To work for this constitutes a great task and challenge for all of us.
I am aware that I only mentioned some of the problems which should be discussed,but if we promote the concept of a comprehensive rehabilitation,then independently of the fact that we may speak from a national or an international position,we always should put the disabled persons at the centre of our considerations and coordination measures aiming at the disabled persons' greatest possible integration into society.Uncoordinated parallel medical,vocational and social measures have to evolve into a coordinated system which enables disabled persons to use their capacities through their work and to reduce their dependency of third parties by the improvement of their basis of existence.But human life is also conditioned by feelings and emotions,by one's aspiration to happiness and recognition and by the feelings of love and suffering.Family ties and social links thus are of the greatest importance especially for disabled persons and should be very much taken into consideration within a comprehensive rehabilitation program.When in the next few days you will discuss the various questions,please always remember that our joint aim,the full integration of disabled persons into our society,should be the basis for all activities because our society is an entity which can only achieve perfection by the joint efforts of all its members.

Realistic Approaches-Looking Ahead Towards Comprehensive Rehabilitation-

Keio Plaza Inter-Continental Hotel
Tokyo, Japan

Copyright 1989
Japanese Society for Rehabilitation of the Disabled
All rights reserved. Printed in Japan.
Edited by
The Organizing Committee of 16th World Congress of
Rehabilitation International
Published and distributed by
Japanese Society for Rehabilitation of the Disabled

Title:
16th World Congress of Rehabilitation International No.1 P.1～P.57

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