LOOKING AHEAD:REALITIES AND POSSIBILITIES

LOOKING AHEAD:REALITIES AND POSSIBILITIES FOR SUPPORTING APPROPRIATE CARE OF DISABLED PERSONS AT HOME AND IN THE FAMILY

J. VAN LONDEN
Director General of Health, Ministry of Welfare, Health and Cultural Affairs, The Netherlands

Ladies and gentlemen,

The theme of my paper, "Care at Home and in the Family", seems at first sight to be appealing in its simplicity. And it fits very well in the overall theme of this morning: "Looking Ahead: Realities and Possibilities". "Home" and "the Family" are two things with which we have all been familiar since our childhood. They are the key concepts which shape our early social development. For most of us, the words "home" and "family" will recall personal experiences. This inevitable personal touch is strongly influenced by the place where one lives, as well as by one's age, culture and socio-economic situation. It also means that the apparant simplicity of our theme requires some qualifications, particularly in the context of a World Congress, which brings together people from so many different countries and organisations.

This is why I would like to ask you not to take what I say at face value, but to translate it into terms of the social and cultural context of your own country or region. Only in this way will we be able to assess whether "care at home and in the family" deserves greater support in our countries and whether there is much in common between the situation and potential in the Netherlands and your country. In any case you may agree that it is essential to recognise the importance of those key concepts - home and the family - when making a policy on rehabilitation and social integration. "Home" and "family" are, so to say, our basic tools - for the able and for the disabled person.

I should like now to say something about modern and actual concepts with regard to home care in the Netherlands, and about the potential which exists for further development. I should like, in particular, to describe the initiating and sponsoring role of the Dutch Council of the Disabled. As far as the possibilities for the future are concerned, one does of course have to rely on a certain amount of speculation. Yet developments in this field do already have the support of a wide cross-section of those involved in any country. The Dutch government has initiated a Steering Group for research in future development in the Health Care sector. One topic for research is comprehensive health care and welfare care in the so-called front line, or home care.

First of all, however, I should like to define what I mean by "home care". By summarising its various characteristics, I hope to make it clear how well home care accords with the context and aims of this, the 16th World Congress of Rehabilitation International.

Home care, then, has the following characteristics:

- It is based on the demand and need for care of the person, patient or client and those around him.

- Must include a combination of functions agreed upon by the person, health care services and social services, ie. must be sufficiently tailored to the needs of the person, patient or client, and it must be provided for in, or within reach of, his or her home in such a way that the care provided is effective and efficient and gives satisfaction to the person, patient or client and her/his nuclear family.

You may find this definition of home care insufficiently precise. After all, things are often made make-believe easy for us by multiple choice questions which suggest that there are always clear-cut options and dividing lines. Our understanding of home care has no place for such over-simplifications. Any attempt to define home care must begin with the individual, with his or her needs or opinions. The differing needs of individual patients and those around them excludes the possibility of an allembracing definition.

Nevertheless, one can, by way of example, list some possible elements which might feature in an individual home care composition. These could include (para)medical assistance, adaptations to patients' homes, the provision of information, the organisation of transport, technical aids and a helping hand for such simple things as shopping, a daily contact, conversation, communication - if wanted.

On the other hand, home care is not an unlimited field. Precisely because we wish to place the client and his immediate family or associates at the center of our efforts, their own physical, psychological and emotional limitations will tend to define the limits of our activities. We need to establish a careful balance between patients' means, capacities and faculties and of their families at one side, and at the other side the burden placed on them, particularly where long-term home care is needed.

A second limiting factor is the quality of the care, the extent to which it must meet specific needs. Some patients or clients need one or more forms of specialist assistance which - up till now - cannot be provided in the home. Our ideas of home care need to make more allowance for cooperation with those who can provide such special assistance. We need to perform research to develop new methods, techniques to bring specialist care to the home and to facilitate a more comfortable home life. A feature and aim of home care should be that it enables the client to continue to function properly in society. Man is a social being, and his scope for personal development and integration or reintegration are inextricably bound up with one another. Integration has therefore a double meaning in home care - it is a feature of it and one of its goals. The client as a social being is at center stage. A creative home care package needs to be put together in the light of the client's capacity. Care must be taken not to marginalise the client, but to involve him in ordinary society. Measures which isolate or stigmatise the client can only hinder the progress of reintegration. In this light we can see creative home care as providing a basis for further integration. So home care provides not only compensation for handicapped faculties, but also strengthens and supports peoples' personal capacities.

A third limiting factor in daily practice, of course, are the financial means available. In the Netherlands a proposal has been put to the Parliament to reconstruct the social health security system, in which home care is fundamentally integrated.

As for the future possibilities, there are still considerable social obstacles to overcome before the kind of home care, which I defined earlier, can become a general reality. In earlier decades, we tended to concentrate upon the supply side of services, and devoted insufficient attention to the client. There were complaints about this state of affairs, and rightly so, both from professionals and from the people concerned. Nor did the parents of handicapped children or the disabled themselves remain silent. They used their democratic rights and made a direct approach to the government. The Council of the Disabled, an umbrella organisation bringing together fifty organisations for the physically handicapped, entered into discussions with the government. In 1986 the Council published a report entitled "Home Help for People with a Handicap". The report described the existing system of home help and the conditions which home help is required to meet. It concluded with a list of the problems which were being experienced, and some suggestions for solving those problems and creating new opportunities. The report is a statement of the current situation, written by the people at the center of the home care concept. They have also provided us with proposals for possible future developments. As citizens in our society, they have not waited passively on the sidelines, but have come together in the Council of the Disabled and set about looking for solutions.

I believe that there have been some changes for the better in recent years. Examples can be found in the rehabilitation of people with motor dysfunctions and in the provisions of help for the blind and other visual disabilities. Home care will have to be improved and extended in the years ahead. We hope, as in previous years, to benefit from the experiences of other countries. I expect that (Dutch) organizations representing handicapped people will continue to play an important role.

Finally, I should like to express my special thanks to our Japanese hosts for organising this, the 16th World Congress of Rehabilitation International. Many visitors to the Congress will have obtained an initial impression of your country from the available literature. One publication, which I would recommend, is the book by Richard Halloran, who for years was Tokyo correspondent of the Washington Post. Speaking from his long experience of your country, Halloran warns us that we should not expect to understand Japan's character and culture overnight. Halloran believes that Japan has repeatedly succeeded in adopting the positive aspects of life in other countries without thereby damaging its own culture. Halloran calls this art of selective assimilation a "Japanese speciality", from which we can all learn a lot.

ON COMMUNICATION

SHUNCHO HANADA
Deputy Delegate, The Japan Council of the International Year of Disabled Persons, Japan

Mixture and Disparity

I am the deputy delegate of the Japan Council of the International Year of Disabled Persons - an organization consisting of some 100 groups made up of disabled people, their families and related persons. My regular occupation would be classified as poet and author.

Welcome to Japan. Let me extend a most hearty welcome to every one of you. I should like to ask you about your immediate impressions concerning Japan. Upon seeing Japan, have you seen any resemblence to your own country as it was in the past? The future? Or the present?

This should differ, depending upon the background of your own country. Furthermore, there are differences within Japan itself, depending upon what you saw and in which part. Even in Japan itself there are places that have kept up with the times, and those that have lagged behind. To exagerate somewhat, both the past and the elements which cause one to imagine the future have been blended almost to perfection and exist in a state of mixture. For example, one may come across a hotel which allows freedom of movement for people in wheelchairs and in other cases, railroad stations and trains that have no such facilities nor any sign of consideration of such conveniences. A pension system exists, guaranteeing some economical income - though insufficient - yet a system of aid and assistance in day-to-day activities for the disabled is all but non-existent.

What is thus to be observed in terms of time as mixture would probably be regarded as disparity if this were to be observed in terms of districts.

There necessarily exist major differences between cities such as Tokyo and Osaka, which have rehabilitation facilities, and other areas which lack them. Even with buildings, there are some which are wheelchair-accessible, and some which are not. The same can be said of braille blocks.

Thus, when such mixture and disparity exists in the country of Japan, the trend would become more pronounced if we were to make the same observations for the entire world, in order to overcome such differences and thus enable any person in need of rehabilitation to receive such services in their area of residence. I am certain that this Congress, being held in the Orient for the first time, is a first step in our efforts to overcome disparity on a worldwide scale.

Speaking of under-development, the United Nations has pointed out that with regard to disabled people, more aggressive measures should be directed to those with mental disabilities, disabled females and refugees from devastated areas. I am certain the problem of mentally disabled people and disabled females will be dealt with at this Congress so I will not elaborate upon this. But just one word on the subject of refugees:

The majority of refugees can be regarded as people who have suffered from the ravages of war. There is no mistaking the fact that many people have become handicapped or disabled as a result of war, and have suffered resultant hardships. If we are to seek progress in the field of rehabilitation, it is imperative that peace be maintained at all costs.

Technology and Humanity

"...The outlook for the future has planned for the integration of the latest technology in the field of biomedical, biological and information engineering and the needs of handicapped persons..."

These were the words of Ms. Susan Hammerman, R.I. Secretary-General. There is no doubt that new technologies in these fields will play an important role in the future of rehabilitation activities. A glance at what goes on around us would reveal many such phenomena. Though not primarily designed to assist the disabled person, the very act of mechanization seeks to assist or replace the functions of the hands, legs, voice or brains of the human being. Such acts are bound to be of help in the day to day life of the handicapped person, much more so than for the non-disabled person. When features are included to make the design easier for disabled people to use, this is most welcome. Of course, it goes without saying that cheapness is also necessary in that respect!

I'm going to pull a surprise on you now. The instrument I'm showing you now is called a "Talking Aid". Pushing one key produces a sound. By combining several keys consecutively one can produce words. One can also input frequently used phrases such as "Good morning everbody!" using a minimum of keys. This device was designed specifically for people with cerebral palsy who have speech difficulties, as well as problems with their writing ability. As I understand it, this is an application of the technology used for TV games and robots.

In my case, I am able to converse person to person or in a small group, as long as I am allowed to familiarize myself; but when there are more than ten people in a group, or with a person I meet for the first time, I lose my power of speech. For me, this is a convenient tool, and for anyone suffering a more severe loss of speech than I, this should be a delight for them to use. However, Japanese is plagued with words which have the same pronunciation but different meanings. Rather than Japanese, which has not yet been fully researched in terms of philological elocution, it should be more practical for use with the English language.

Be that as it may, the number of persons strongly seeking to use this tool to increase communication and enrich their lives, is on the increase. But there are others whose opinions do not favour this tool. Certain medical opinions believe that to fully rely on this instrument would cause the user to gradually neglect their ability to speak, and thus compound their disability. Others feel that since the speaker is making great efforts to speak, their audience should likewise be making great efforts to listen. There are those of the opinion that humans communicatenot only with words but also through facial expressions and bodily actions, showing their emotions through certain body language, so that fewer words need to be spoken, but body language should be more emphasized. Others hold the view that, whilst this tool is convenient, there is something "cold" about a machine, and that "cold" objects shouldn't enter the picture when two human beings are trying to communicate.

I feel I have not been very deft in expressing my thoughts. What I've tried to say is "Would using a machine run the risk of losing the human element?" A psychological or philosophical question has come to the fore.

In this instance, it may be possible to deal with the matter by comparing the man with speech impediment using a talking aid, to the disabled person unable to walk, who uses a wheelchair. The problem existing between "technology and humanity" - as is the case in most other aspects of society - becomes an element of deep concern relative to rehabilitation.

This particular concern is possible loss of humanistic elements and the damaging of person to person relationships. It is the fear of loss of humanity. From the point of view of people handicapped in this way, they crave being responded to as human beings, and don't want to be handled as though they're machimes....These are some of the feelings which cause increasing concern over this problem of machine/human interface.

Overcoming Old Concepts

As mentioned previously, Mrs. Hammerman stated "...Integration of new technologies in the field of rehabilitation engineering and the needs of the handicapped person..."

This integration should not just take place through the efforts of those engaged in engineering and medicine, but also with the personal participation of the disabled person. This person should be fully involved in giving feedback and guidance to other personnel regarding any required changes in speed, direction or promotion of all concerning their life. This should not be merely promotion, but a checking function on the part of the disabled user. The problem of "technology and humanism" that we touched upon before should, of course, be dealt with at this point.

To be capable of this checking function, there is need for the disabled person, or the disabled person's association, to have the strength to get involved. There is probably a need to promote and appeal for them to realize they can extend their efforts and motivation in this way.

There will also be need for disabled people to begin to change the way they think about certain problems...
One young person with cerebral palsy, during a group discussion about talking aids, said "...Why shouldn't we courageously recognize the existence and usefulness of such items, and be willing to use them when available?..."The word "courageously" has the connotation of recognizing with objectivity our impairments AS impairments, and freeing ourselves of false pride. Also, I would dare to say that the youth also meant we should be able to use such items of our own free will, and not have them thrust upon us by others.

Without going as far as changing one's basic opinions, overcoming one's old concepts would promote integration of new technologies and personal needs. An example would be this overhead projector (OHP) here, which is designed to assist those with hearing disabilities. But I would like to use this myself - not to assist my hearing, but as an aid to my talking. When I ask for the use of an OHP, however, I am always asked how many hearing-impaired people will be in the audience? When I begin talking using the OHP, I can sense clearly the attention of the audience shifting from myself to the OHP. It is not a pleasant sensation, but I just have to resign myself to it "courageously". From a different viewpoint, even though I am using a microphone, most of the audience have become people with hearing difficulties. This is where the OHP becomes a most useful tool.

Of course, using the OHP is dependent upoon my preparing and submitting a manuscript in advance, and the person handling the OHP being able to distinguish what I'm saying. But at least what is ceraain is that more people can hear what I have to say if I use this tool than if I were to just talk. By diversion of concepts, therefore, a tool designed for people with hearing difficulties is put to good use by someone with speech difficulties.

I'm certain that this freedom, flexibility and eagerness in search of concepts will play a vital role in the future of rehabilitation activities.

Easier, Broader

I have discussed the question of speech and communication. This is the area with which I have most inconvenience, and it is thus my greatest concern. This is one particular area in which its mere complexity has caused it to have the slowest development in both study and applied rehabilitation methods....this I feel when I compare the aids available to supplement the functions of arms and legs, for example.

Of course, that's not to say that in other fields, the technology and policies related to disabled people are anywhere near sufficient. I am certain that the points I've raised exist in some form in these other fields also.

Finally, I wish to end my presentation by mentioning communication in a totally different light. It may be due to peculiarities of the Japanese language, but the language used in various fields of medical study and engineering (especially high-tech) is too difficult for the layman to understand. It's causing a rift between those concerned with rehabilitation and disabled people, as well as a disparity in availability of pertinent information and knowledge. Couldn't the language be made easier to understand? How's this situation in your respective countries?

Whatever concept is discussed, there is need for it to be made widely known in order that it may fulfill its mission. I have great expectations of Ms. Margaret Ansty, Director General of United Nations Social Development and Humanity Center, and in her efforts to direct enlightenment and the diffusion of knowledge, that superb concepts may become more readily understood and propogated.

THE MID-POINT OF THE UNITED NATIONS DECADE OF DISABLED PERSONS AND PROGRESS TOWARDS THE EQUALIZATION OF OPPORTUNITIES

HENRYK J. SOKALSKI
Centre for Social Development and Humanitarian Affairs, United Nations

Mr. Chairperson, Ladies and Gentlemen,

I am very much sensible of the honour which you have accorded the United Nations Centre for Social Develoment and Humanitarian Affairs in inviting its representative to speak at this Plenary Session. The original programme of our meeting indicated that Miss Margaret J. Anstee, Director-General of the United Nations Office at Vienna, with major responsibility for social policy and development within the United Nations, would address you today. Miss Anstee regrets profoundly that she is unable to be with you, but sends her warmest regards for the success of your deliberations, and asks me to take this opportunity to express once again the appreciation of all at the United Nations of the enormous contribution made by Rehabilitation International to the carrying out of the World Programme of Action concerning Disabled Persons, and to our joint efforts during the United Nations Decade of disabled Persons.

Our themes this morning include both the mid-point of the United Nations Decade of Disabled Persons and one of the major principles of the Decade, that of equalization of opportunities. Allow me, however, to start with a reflection of a more general nature, as much relevant to UN the programme on disability as it is to all other areas of the Organization's involvement.

The United Nations was established at a time when convictions were running very high, convictions held by several quite distinct groups in the world that the model of society which they believed represented the best solution for humanity's problems would prevail. It was in this atmosphere that men and women of many different political persuasions and cultural perceptions felt that, in contrast to the hopelessness and pessimism of a previous generation, their energetic participation in apparently established trends would be rewarded within measurable time. During the first decades of its existence, it was expected that the United Nations, by virtue of the authority vested in it by governments and hence by peoples, and by means of its global responsibilities and its wide resources, both financial and intellectual, would intervene almost singlehandedly to put humanity on a new path to a splendid new world. Since then a mood of disappointment and some bitterness has prevailed. Its perceived share of action dwindled significantly. I strongly believe that the pendulum has now been moving back to a central position, and one more reasonable than either of the extremes: both outside it, among governments and the public, and inside it, among its policy-makers and the staff which carries out its work, it is realized that the United Nations system has a significant role to play in resolving societal problems, but that it can play this role only as a partner with other categories of policy actors, categories which include not only governments, but also organizations which represent the interests of those sections of humanity concerned to build a sane and humane society, including particularly those sections who have hitherto borne the brunt of its insanity and inhumanity.

The experience of the last ten to fifteen years has also shown a new resolve among many categories of persons who are vulnerable and disadvantaged that they are no longer willing to accept their condition as one that is a part of the natural order of things, unavoidable, insoluble. Within the United Nations, the perceptions of those involved in efforts on behalf of the vulnerable and disadvantaged have been affected by the general spirit, first of unbounded optimism, and then of increasing pessimism. Nevertheless, an awareness of real progress achieved in spite of changed global circumstances supports a contemporary perception of the future which I would like to describe as one of optimism tempered by caution, and enthusiasm tempered by experience. We are better informed now than in the 1950s of the complexity and sometimes intractability of the varied interactions among exogenous and indigenous processes which take place as global economic structures adjust to their own contradictions as well as to the impact of revolutions in technology and transformations in forms of organization. We are better informed now of the intricacy of relationships among individual perceptions and goals; forms of family, community and societal organization; processes of manipulation and mystification in social and political life; and many other factors, including demographic and environmental trends. This knowledge has shown the tasks in front of us to be indeed very great. But it has also shown more clearly than before the nature of the difficulties, and this greater sense of reality should make it possible to apply with more precision the resources which are available to us. There is now much talk of a limitation in resources, and this constraint is both real and grave in terms of immediately available finance. At the same time, the developmental gap between considerable parts of the developing and developed worlds further widened. Nevertheless the technological and organizational resources available to humanity are greatly expanded compared to those available even during the first decades of the United Nations' existence. One need only consider our immense capability in the area of sharing knowledge and experience, and in the communication of perceptions and concerns, or in the area of intervention in the physical world.

Could it be that humanity is moving into a period of quiet confidence and determination to tolerate no longer quite inexcusable waste, destruction, exploitation and intolerance? Could it be that we are re-capturing some of that early Renaissance perception that humanity is capable of everything provided that its will is sufficient? I would like to think that this is the case.

Such is the backdrop against which I would also propose to view United Nations efforts in the field of disability. We have gone a long way to reach the present juncture. Indeed, much has been achieved, but only too often we see it as too little, because in the face of needs and aspirations, it is just not enough.

For the last year, we have been saying that we are in the mid-point of the UN Decade of Disabled Persons. As a matter of fact, we are not any more. Time is passing quickly. What is left is just a little more than four years, and the international community is still discussing how to approach and what to do about the recommendations of the Global Meeting of Experts to Review the Implementation of the World Programme of Action concerning Disabled Persons at the Mid-point of the Decade, held at Stockholm, more than a year ago. Although the first half of the Decade witnessed very tangible achievements, nationally and internationally, the general public's perception of progress in implementing the World Programme of Action is rather on the negative side.

During the last five years, the number of disabled persons in the world has grown. It will increase even more in the years to come, as a result of malnutrition, growing poverty, violence, wars and demographic trends. The deteriorating social and economic situation poses a greater challenge than ever before to the world community in meeting the needs of disabled persons.

It is believed that the momentum of activity generated during the International Year of Disabled Persons has not been maintained and, in general, the Decade of Disabled Persons has not been presented in such a way as to arouse the interest of Governments, organizations or the public. The World Programme of Action is not adequately known and has not been widely applied or implemented. It is also believed, that while there has been, during the first half of the Decade, an increase in the participation of disabled people in different sectors of society, the goal of full and equal participation is far from being achieved; disabled people are not an integral part of the decision-making process or of the administrative machinery of intergovernmental bodies, regional entities, Governments or organizations. While the creation of organizations of and for disabled people has been an important development during the past five years, their numbers, coverage, effectiveness and funding are insufficient. The lack of co-ordination in most countries between local and national authorities and disabled persons' organizations is a further obstacle to the improvement of the situation.

Insufficient or inadequate information is another serious hindrance to the effectiveness of the Decade. Information is still very far from being accessible to all concerned and is not communicated in forms that could be used by those with impairments of vision, hearing and comprehension. Too many items produced by Governments, organizations and the mass media continue to be based on outdated concepts of disability and a faulty understanding of appropriate methods of dealing with it. There is little evidence that disabled people or duly informed organizations are consulted on correct terminology, emphasis or presentation.

A main obstacle, however, to the success of the Decade, to the implementation of the World Programme of Action and improved public awareness of the problems of disabled persons is the scarcity of national plans that are comprehensive, effective and based on the concepts expressed in the World Programme. Both an immediate consequence and perhaps also a cause of the absence of such plans is the lack in many countries of national co-ordinating machinery for that purpose. Where it exists, it still requires a stronger and clearer mandate to act more effectively.

Last but not least, the inadequacy of the funds available for work in the disability field and, not infrequently, improper weighting of priorities in their allocation, are both the cause and effect of the low priority generally assigned to disability issues. That situation is reflected also in the insufficient funding of the Decade and of the implementation of the World Programme of Action.

In the United Nations, too, budgetary provision for the promotion of the Decade and the implementation of the World Programme of Action is in no way proportional to the importance of the subject or the number of people affected. Similar contributions for extra-budgetary funding have declined rapidly since the International Year of Disabled Persons and only a few Governments have continued to contribute to the Voluntary Fund for the United Nations Decade of Disabled Persons.

As long as an overall negative perception prevails, one cannot speak of sufficient progress in the equalization of opportunities for the disabled.

It would be a gross error though to conceive of the current situation predominantly in negative terms. For, despite all the difficulties, never before has the awareness of the needs of disabled people been as sensitized, and indeed increased, as it is now. The precept of "One in Ten" has become a well established point of departure for action at international level. Those of us directly involved in disability issues realize full well that with a relatively modest amount of funds for global prevention and rehabilitation, still before the end of the Decade of Disabled Persons the precept of "One in Ten" could be turned into at least one of "One in Twenty".

The increased awareness of the problems of persons suffering from physical, mental and sensory disabilities created during the International Year of Disabled Persons and the first five years of the Decade represents an important step forward in social thinking. The framework of the World Programme of Action - that of prevention, rehabilitation, equalization of opportunities, full participation and equality - has proved to be a valid basis for progress wherever applied. The Secretary-General's "Report on analysis of monitoring questionnaire", prepared for the Stockholm Global Meeting of Experts, last year, contains a wealth of information on the positive record of achievement in efforts to improve the situation of disabled people, in the growth of their organizations, in action on policy-making, policy co-ordination and technical assistance. Suffice it to note that while in the 1960s there were only 15 national population censuses or household surveys with disability-related questions, their number increased to 76 during the first half of the Decade. A number of governments have expressed important political commitment to act on disability problems and adopted their own policies and programmes.

Co-ordinated policies and programmes have been successfully adopted by some inter-governmental bodies. Generally, there has been more research and more exchange about disability, as well as of information, increased mobility, and participation in leisure and sports activities on the part of disabled persons. The contribution of United Nations bodies and organizations to all those endeavours has been an important one.

Within the United Nations there have been pressures even stronger than those experienced at national level. Nevertheless, in spite of severe financial constraints, the Organization does still have a vision. Commitment and priorities remain unaffected. Increased effectiveness is being sought by means of rationalization of organization and technological modernization. Last year, the Secretary-General concentrated all social policy matters under the authority of a single Under-Secretary-General, at Vienna. The generosity of a number of sources, including those in Norway, has made it possible for the Secretary-General to appoint his Special Representative for the Promotion of the Decade of Disabled Persons, who is actively engaged in working out a concrete promotional strategy for the remainder of the Decade. The generosity of the Government of Sweden has just made possible the strengthening of the Disabled Persons Unit in the Centre for Social Development and Humanitarian Affairs and it augurs equally well for the establishment of posts for Special Technical Advisers in Africa, and in Asia and the Pacific. Finland is also contemplating a significant contribution to strengthen our staff resources. The Government of Japan has most recently contributed 100,000 US dollars to the Decade's Trust Fund, which, to date, disbursed over two million dollars in support of more than eighty catalytic and innovative disability projects.

While clearly recognizing that it is the responsibility of Governments to provide resources for the implementation of the World Programme of Action, the NGOs community has come out with a very timely proposal that a global campaign be launched to raise awareness and mobilize resources in support of the Programme's objectives. The Secretary-General of the United Nations has given his personal support to the initiative. Consequently, the General Assembly, at its forty-second session, called upon "Member States, national committees, the United Nations system and non-governmental organizations to assist in a global information campaign to publicize the Decade through all appropriate means". Also the Economic and Social Council, last May, reiterated the need to launch a special global awareness and fund-raising campaign to give added momentum to the Decade.

In this regard let me emphasize that we in the United Nations share in the consensus among all who are engaged in this work that success can be possible only by means of full partnership among the various categories of organization involved, and by means of the constant and real participation of disabled persons themselves at every level of policy formulation and implementation. The partnership established among non-governmental specialist organizations, governments and the United Nations in support of disabled persons has been one of most constructive and rewarding of any in which the United Nations has been engaged. United Nations' relations with Rehabilitation International are a vivid example of the spirit of co-operation between it and NGOs. Its success has an even wider significance, in that it makes evident in the clearest possible way the potential of international co-operation in the solution of the real problems that humanity faces in all societies; it does so by means of a unique equalization of opportunities of all the participants of the international concert.

Major recommendations which emanated from last year's Stockholm Meeting of Experts considerably reinforced the principle of equalization of opportunities for disabled people as the guiding philosophy for the Decade based on the recognition of the human rights of disabled persons, first as citizens of their countries with the same rights as those of other citizens, and only secondarily as users of social and other services. In relation to prevention and rehabilitation, equalization of opportunities is a longer-term and contextual process of very considerable complexity with regard to the factors which are relevant, the disciplines which are involved and the measures which must be brought to bear. A technically rehabilitated person may still face numerous and severe barriers to full and satisfying participation in society. Active discrimination combined with passivity and neglect still too frequently prevent the full realization of the opportunities which medical or therapeutic measures may have provided. In practical terms, equalization of opportunities is all-encompassing - prevention of disability, rehabilitation and more. It is a goal that transcends the notion of social integration. Hence, much more rapid and extensive progress toward the equalization of opportunities appears to be an essential priority in our future programmes.

When the extent and depth of ignorance and misconception, and the resultant frequency of irrational behaviour, including active discrimination, are recalled, and when the socio-cultural complexity of the societal context for this is considered, then the task of fully equalizing opportunities for disabled persons appears very great indeed. Moreover, the majority of disabled persons are individuals who only too often suffer additional forms of vulnerability, discrimination and exploitation, because they are at the same time old, or female, or migrant, or racially or ethnically distinct, or poor and destitute. Thus, interwoven with the complexity of societal behaviour to the disabled person in respect specifically to his or her disability, are the complex structures of political, economic and social inequalities, which exist within and among national societies, and which affect high proportions of the population, able-bodied and disabled. In such circumstances, the difficulties which face the task of achieving equalization of opportunities simultaneously in respect to each of these distinct but mutually supportive obstacles may appear quite insurmountable. They are rendered even more awesome when it is realized that the structure of inequality is not merely a passive inheritance, but to some degree an actively renewed construct. For, there appears little doubt that the real impairments suffered by disabled persons, just as the imaginary impairments attributed to individuals on the basis of quite different criteria, such as age or sex or the minor physiological characteristics which make possible racial distinction, are frequently used as justification for the maintenance of hierarchies of privilege and exploitation.

An essential element of the entire international effort during the remainder of the Decade should be an emphasis on the concept that disabled persons enjoy human rights and fundamental freedoms to the same extent as do the non-disabled. The rights established under the aegis of the United Nations within the corpus of international law and supportive instruments, having substantial moral significance, are applicable without discrimination of any kind, including discrimination related to impairment and disability. Full enjoyment of human rights is equivalent to equalization of opportunities. It is not something that society may bestow on disabled persons as a favour, as charity, or even as compassion. It is quite simply the fulfillment of legal obligations and moral imperatives already incorporated in international law and in many national constitutions and legislations. Clearly, the fact that this concept of human rights is well realized in law, constitutes a formidable base for efforts to fully equalize opportunities for disabled persons. Without much further work, this does not guarantee such opportunities, but the absence of such a corpus of human rights and fundamental freedoms would certainly make the task very much more difficult.

These rights and freedoms must be constantly emphasized, and moreover, constantly and energetically claimed by the disabled themselves; but to realize them needs supportive intervention. One of the most important lies in the revision of national ligislation. Rehabilitation International has already collaborated with the United Nations in tackling this issue. The International Meeting of Experts, which we organized together in 1986, resulted in the publication of the study on National and International Legislation on Equalization of Opportunities in 22 Countries. A series of generous contributions by the Government of Norway contributed greatly to the preparation of an unprecedented United Nations Manual on the Equalization of Opportunities for Disabled Persons. Support from the Swedish International Development Authority (SIDA), enabled the United Nations to come out lately with a set of Guidelines for Workshops on the Equalization of Opportunities for Disabled Persons.

It should be stressed, however, that even the potential of a fully supportive set of laws must be further realized in order to be effective. This can be done by means of strengthening mechanisms whereby disabled persons are made aware of their legal status, and are helped in fighting for their rights against ignorance and abuse. An essential mechanism is a strong network of organizations representative of the disabled and operating within each country at local and regional as well as at national levels. Moreover, at the national level, the existence of a joint governmental - non-governmental watchdog body, having full powers of monitoring and evaluation and intervention, is essential both to safeguard the rights of disabled persons as well as for generating constant pressures for awareness and adjustment throughout society. Through such mechanisms disabled persons themselves may participate effectively, realize their responsibilities as citizens, and live and work in society on equal terms with all other of its members, as a powerful means to dispel prejudice and tendencies to marginalize persons with disabilities.

In a speech made in 1985, at the Woodrow Wilson Centre for Scholars in Washington D.C., the Secretary-General of the United Nations spoke of his vision for the year 2000 when, although there would still be disabled persons, there would be universal respect for people with disabilities, adequate opportunities for their skills and talents to be utilized in all societies, proper care where care was needed, and those causes of disability subject to human control substantially reduced. In view of the strength of the psychological, cultural, social, economic and political obstacles to which I have alluded, we must ask ourselves if it is too much to hope that in the short time span of twelve years such a state may yet be achieved. My response to that query would tend to be a positive one. But prior to the year 2000, there still is the year 1992, the last of the United Nations Decade of Disabled Persons. Unless some pronounced progress be achieved by that year, we shall not be able to realize the vision of the second millenium target. Therefore, the first task to be undertaken is to embark upon the best means whereby our joint energies may be re-generated and most effectively applied.

TOWARDS COMPLEX SOLUTION OF DISABILITY PROBLEMS IN THE USSR

A. M. LUKYIANENKO
Minister of Social Security of the Ukrainian SSR, Kiev, U.S.S.R.

In our country the Government policy concerning disability is based on complex approach to prevention of disability and soluyion of disabled person's problems.
I would like to elucidate the approach of the Soviet Government to solution of problems related to disability by showing how those problems are being dealt with in Ukraine - one of 15 constituent republics of the Soviet Union - with its population of 51,5 mln people.
In the Ukrainian Republic as well as in the whole country the national policy aimed at preventing disability covers environment protection measures including the control of the air, water and soil pollution, and measures of social and economic character providing health care and rehabilitation of disabled persons.
Annually the Council of Ministers of the Ukrainian SSR adopts the programme of action aimed at disability prevention which is to be realised by government bodies and agencies, industrial enterprises, health and social security institutions.
At present the greatest attention is paid to protection of industrial workers' health, to prevention of their disablement and medical rehabilitation of disabled workers within the shortest period of time with due concern for their consequent physical condition.
With that end in view efforts are made to get all hard and unhealthy work processes mechanised and automatized, to improve labour conditions at industrial enterprises throughout the area of the republic.
The administration of factories and establishments in cooperation with the trade union organisations and representatives of health bodies is bound to work out and realize complex plan of measures under the programme "Zdorovyie" (Health").
At any industrial enterprise there are functioning teams formed of engineers and physicians who are responsible for improving labour conditions. They also deal with problems of adequate job placement of disabled workers paying due regard for particular characteristics of the working environment.
The working conditions are being assessed at every job place, shop and at every factory as a whole, which facilitates working out a long-range programme of action aimed at improving labour conditions and providing optimum job places with the working conditions suitable for handicapped persons.
Great importance should be attached to early preventive medical and social measures aimed at decreasing the number of persons becoming disabled. To this end a sick worker ought to get medical treatment as long as required to recover, sickness benefit being paid to him without time limitation.
During the last 5 years in the Ukrainian SSR every 90 out of 100 patients with favourable clinical diagnosis returned to their work after early medical and social rehabilitation.
Well known is the fact that disabled persons require intensive medical treatment for rather prolonged periods of time. State expenditures for medical services rended to the disabled 3-4 times exceed the cost of medical services provided to able-bodied people.
Alongside with medical rehabilitation of the disabled important is social and vocational rehabilitation provided by social security bodies. Social and vocational rehabilitation measures cover vocational training and employment of handicapped persons in ordinary industrial enterprises or in sheltered workshops, or if necessary at home; rendering other necessary social services such as providing handicapped persons with prosthetic and orthotic appliances, transportation means,working aids and convalescent treatment courses at health resorts.
Employment of disabled persons is provided by local social security bodies in strict accordance with labour recommendations adopted for each particular case by special Expert commissions for medical and labour evaluations. Suitable job placement is supposed to improve the disabled person's physical condition and spirits, to raise his position in the family and society.
Any disabled person is afforded the opportunity to get a vocational training course free of charge, with due regard to his state of health, and to get a job at an ordinary state factory or organisation, as well as in a specialized workshop designated for employment of handicapped persons. There are special workshops for employment of tubercolosis patients, deaf and blind persons, psyhiatric patients and those with severe cardio-vascular diseases.
The specialized enterprises enjoy certain advantages in taxation as compared with ordinary industrial enterprises. Employed disabled persons are also entitled to significant priviledges such as lower output quotas, a shorter working day or week, additional intervals during a working day and so on. Some of them are provided with the opportunity to work within the home. In such cases the administration of the enterprises deliver raw materials and specially adapted tools to the handicapped and collect the finished articles.
Vocational training of disabled persons may be provided in different manners such as training in the working place, in ordinary educational establishments or in vocational training schools supervised by social security bodies.
In Ukraine there are 5 specialised vocational training institutions established for training 2000 disabled persons. During the training course they get full maintenance, medical care and accomodation if necessary in sanatoriums. On graduating from these educational institutions the handicapped persons may be placed in industrial enterprises, in agricultural farms or in everyday services establishments.
A lot is being done for rehabilitation of the handicapped by voluntary associations of persons with impaired sight and hearing. These associations run their own training production enterprises where the handicapped can get a vocational training course and suitable job placement.
Effective rehabilitation of many handicapped persons is impossible without provision of prosthetic and orthotic services.
In our country we have a developted net of prosthetic and orthotic production centres with out-patient and in-patient clinics.
The in-patient clinics make more complex fittings of prosthetic and orthotic appliances to invalids, train them in using these appliances, provide courses of mechanical therapy and physical exercises. If necessary the prosthetic services are rended to severely handicapped persons within the home by mobile teams consisting of medical and technical specialists.
Nevertheless I would not say that all disability problems are completely solved in our country.
Thus, we feel an imperative need of revising certain legislative acts and regulations concerning ascertainment of disability and employment of disabled persons. There is still unsatisfied demand in supplying rehabilitation technical aids and suitable means of transportation for the handicapped, there are certain problems of access and provision of housing adjusted to the needs of handicapped persons.
Nowadays, due to "perestroika" and democratic development of social life many problems of disabled persons acquire wider publicity ("glasnost" as we say) and a somewhat new approach. A clear manifistation of the changes is the fact that voluntary organisations of the disabled have started to appear (on local, regional and republican levels) throughout the country, that disabled persons have got a voice of their own and participate actively in solution of their own problems together with government bodies and public organisations.

FUTURE TRENDS CONVERGING WITH REHABILITATION REALITIES

DENG PUFANG
China Fund for the Handicapped, People's Republic of China

I am very grateful to you for giving me this opportunity to speak on such a signigicant occasion. Please allow me to wish, on behalf of the 50 million disabled people in the People's Republic of China, every success to this World Congress.

My collegues come to the Congress with a hope to seek friendship and exchanges of experience as well as a good wish to the disabled and the undertaking for the disabled in the whole world. Unfortunately, I can't come to the Congress in person due to my busy schedule and I have to entrust my representative to read my speech for me.

Since 1981, the International Year of the Disabled, disability has become a more and more important issue in the world community and the situation of the disabled in all countries has been imporoved to various extends. Meanwhile, the great progress of science and technology has brought about new hopes to the comprehensive rehabilitation of the disabled. But we have noticed that difficulties still exist in all countries concerning disabilities. The situation of the disabled is still far from the Principles of World Activities stipulated in the "UN decade for the disabled". After years of "welfare policy", governments in the developed countries are trying to adjust or have adjusted this policy because welfare expenditures are too heavy a burden for those governments to bear. In the developing countries, governments have devoted their energy into the industrialization and modernization of their countries so as to change their economic backwardness and failed to list the development of undertakings for the disabled into their national development plans. It is rather difficult to change this situation in the coming years. In this situation, disabled people in all countries, especially in developing countries are facing the chanllenge of how to use and develop
various resources to imorove their conditions and return to the normal social lives.

It is predicted that the present society is in a process of changing from a world of industry to that of information. In the 21st century, it will be a great time for scientific revolution, education revolution, industrial revolution and social revolution caused by the development of high technology. The last decade of this century is the transitional period from the old to the new.

It has become a vital issue for the undertaking for the disabled in such a changing period to choose its road to future, facing the chanllenge to follow up the development of human history. There are several choices but I would like to brief you on our choice in China.

As you know, China is in the first place in the world in terms of its I billion population. The nation-wide sample census of the disabled in 1987 reveals that China has a total disabled population of 51.64 million, accounting for 4.9% of its total population. Among these disabled, 17.7 million are hearing and speaking impaired, 10.17 million mentally retarded, 7.55 million physically disabled, 7.55 million visually impaired, 1.94 million mentally disordered and 6.73 are with multiple disabilities. In this census, dwarfs and victims of leprosy are not included. On an average level, there is one person with certain kind of disability in every five families and about 200 million people are affected by disabilities. The Chinese government has come to realize that a good solution to the issue of the disabled has great impact on our effort in reform and modernization construction, and is trying hard to give its every possible support to the undertaking for the disabled. My government, my collegues and I myself firmly believe that equal right in fact for the disabled in their full participation in social lives is no longer a good saying but something which must be put into action gradually. This has always been the central issue in the undertaking for the disabled. We are marching towards this goal in China with the support of the Chinese government.

Under this guideline, we put special stress on the disabled people's right of work and employment as well as the right of making contributions to the society. Only with these two rights could the disabled get rid of the awkwardness of depending on the state for living and to stand on their own feet with dignity in the challenging society. These are the economic and psychological pre-conditions for the disabled in their full participation in social lives. Encouraged by the government's preferantial policies, labour and employment of the disabled in China has enjoyed a rapid development in the last decade. Welfare factories which provide opportunities of labour and employment for the disabled have been developed through different channels and at various levels and numbers of this kind of factories have increased from 869 in 1978 to 27,793 now, and among them, 24,714 are run by enterprises, neighbourhoods and villages and townships, accounting for 88.9%. The number of disabled people employed in these factories has increased from 48,200 in 1978 to 433,000 now, 340,000 of whom work in welfare factories run by enterprises, neighbourhoods, villages and townships and private-owned ones, accounting for 78.5%. If we add the 400,000 disabled people employed in common enterprises, there are about 800,000 disabled employees in urban area. According to the government policy, social welfare enterprises enjoy an income tax deduction (normally 55% of the profit is regarded as income tax) if 35% of their employees are disabled people. To those enterprises with 50% of employees as disabled, all income tax should be exempted. No doubt, this policy has greatly promoted the labour and employment of the disabled. Now, the Chinese government is working on policies to promote the employment of the disabled in normal enterprises so as to enable the disabled to choose their favourablejobs in a more convenient environment. Many convincing facts have made us aware that the rights of labour and employment to the disabled not only improve the living conditions of the disabled, but also nurture their strong will power. In the coming five years, we will further develop labour and employment of the disabled through the betterment of legislation and policies and lead the undertaking for the disabled in China towards the mode of labour-welfare.

We have also noticed that the development of science and technology has made it possible to regain or compensate the lost functions of the disabled through medical, engineering, psychological and social treatment and other means. Gaining the rights of labour and employment for the disabled means making unremitting efforts in rehabilitation of disabilities which is aimed at resuming functions and abilities of the disabled people to the largest extend. Rehabilitation is a newly-started work in China. We must start from our actual conditions and pay more attention to the practical effect so as to lay a solid foundation and make steady progress. We have drafted an Outline of the Five-year Plan of Work for the Disabled which has been approved by the government. It stipulates that in the five years, we should concentrate our resources on eye surgery to 500,000 cataract victims, orthepidic surgery to 300,000 infentile paralysis victims and hearing and speaking training to 30,000 deaf children. It is a gigantic plan and now we are engaged in making the annual plans for the implementation of this great plan with the support of the Ministries of Planning, Finance, Health and Civil Affairs. We will coordinate with various departments and mobilize the whole society to realize our goals step by step.

As part of China's political and economic structural reforms, the community and township based service network is being established. We are trying to integrate foreign experience with our traditional medicine to utilize the existing medical service network of county-township-village levels and the forthcoming commanity-based service network. Major rehabilitation institutions will play a leading role in China's rehabilitation system, which is based on community service and well suited to the actual conditions in China. The big and medium-sized cities in China such as Shenyang, Dalian, Wuhan and Guangzhou are taking the lead in this endeavour. Three of the four districts in Dalian have set up community service committees. Most neighbourhoods have set up community service stations and groups. A three-level service system has been established, consisting of district as instructors, neighbourhood as the main service units and residents' committee as the grassroot units. 80% of the neighbourhooc in Dalian have established rehabititation stations, nursuries for the disabled children, activities rooms for the disabled, special care service to the mentally disorderc and match-making offices for the disabled. In this way, most of the difficulties for the disabled in their daily lives could be treated at an initial stage. The communitybased rehabilitation developed from townships and neighbourhoods takes the welfare enterprises as its economic foundation. It has great vitality because it is closely connected with China's governmental and social structure. This is becoming one of the characteristics of China's undertaking for the disabled.

China is a developing country. The financial limitation of the state causes the shortage of financial power in our undertaking for the disabled. To broaden our channels of financial resources, we advocate establishing economic entities and supporting our undertaking by enterprises in accordance with the practical conditions in China. Townships composed of an enterprise, a welfare house and a community committee have come into being in more and more cities, townships and villages. The development of commodity economy has provided with favourable conditions to realize our goal of supporting undertaking by enterprises.

China's undertaking for the disabled is seeking its way forward in a difficult but promising situation. I have realized through years of work for the disabled that the barrier of the disabled in their full participation in social lives comes from the disabled themselves along with the development of human civilization and economy. It is hard to imagine that a disabled group of illiterates or semi-illiterates could be fully envolved into social lives. To change this sad situation, we are engaged in developing education to the disabled, including pre-school education, speaking training, basic education and vocational training, together with our efforts in promoting employment and rehabilitation of the disabled. We expect that after our 5 to 10 years' effort, great progress will be achieved in improving the cultural and technical qualities of the disabled through education.

Ladies and Gentlemen, the undertaking for the disabled is a humanitarian cause. Only by upholding the banner of humanitarianism could this cause be deeply understood and widely supported by the society. China is a socialist country. We are fully aware that socialism means nothing without humanitarianism, but socialism opens up broad prospects for the humanitarian cause. We firmly believe that the undertaking for the disabled in China, a country with the largest disabled population, will be greatly developed under the guidance of humanitarianism and with the help from our friends in international rehabilitation organizations and from the precious experiences of our foreign collegues.

In concluding my written speech, the imagination of the situation of the disabled both in China and in the world in the next century comes to my mind. I think more opportunities will be open to the disabled to fully participate in social lives along with the development of science and technology. If we set our goal in accordance with each of our specific conditions, focus our efforts on key issues and do some practical work for the disabled which benefits the most difficult social group with humanitarian hearts, then we will achieve all the goals stipulated in the Principles of World Activities of UN Decade for the Disabled My collegues and I are quite confident of our success in this endeavour.

Mr Chairman, Ladies and Gentlemen, thank you once again for giving me this chance to speak. Please allow me to extend my heartfelt wishes to your good health, successful work and a happy life.

TECHNOLOGY CREATING NEW REALITIES

PREVENTION TECHNIQUES FOR CONGENITAL DISABILITIES: QUO VADIS?

J. LEJEUNE
Institut de Progenese, Universite Rene Descartes, France

THE FUNDAMENTALS OF LIFE
Life has a very, very long history, but each of us has a very precise beginning : the moment of the conception. The progeny and the parents are constantly united by a material link, the threadlike molecule of DNA, upon which the complete genetic information is written in a fantastically miniaturized language.
On the head of a spermatozoon, there is a one meter length of DNA, cut in 23 pieces. Each segment is very precisely coiled to form little rods visible with an ordinary microscope : the chromosomes.
As soon as the sperm has perforated the "zona pellucida", the plastic bag inside which the ovum is wrapped, the membrane becomes suddenly impenetrable to any other sperm. In purely operational terms, it can be stated that as soon as the 23 paternal chromosomes carried by the sperm are put in the same bag as the 23 maternal chromosomes (carried by the ovum), the total information necessary and sufficient to dictate the genetic make-up of the new human being is gathered. Not a theoretical or a potential human type, but the very human being we will later call Peter, Paul or Magdalene.
Exactly as introducing a mini-cassette inside a tape recorder will allow the playing of a symphony, the music of the life is played by the machinery of the cytoplasm, and the new human begins to express himself as soon as he has been conceived.
Soul and body or spirit and matter are so intricately interwoven at the beginning of life that we use the same word, conception, to describe the process by which an idea, a concept, comes into our mind, and to define the genetic process by which a new being, a conceptus, comes to life.
Protected in its life capsule (the zona pellucida first, then the amniotic bag he constructs around himself) the early human being is just as viable and autonomous as a cosmonaut on the moon : refueling with vital fluids is required from the mother vessel. No artificial fluid supplier has yet been invented ; shelter and nurture by the mother organism are absolutely required.

CONGENITAL ABNORMALITIES
Two types of misfortunes, inborn or acquired, can hamper the future.
At the very beginning, an unequitable patrimony could darken the destiny. A misspelling of the genetic message (a "mutation" like phenylketonuria) or a mistake in the binding of the volumes of the tables of the law of life (a chromosomal aberration like trisomy 21) could curb the embryological process or modify chemical reactions. Affected in his flesh and/or in his mind, the child will suffer of a physical and/or mental impairment.
Secondarily, because of the length (9 months) and of the complexity of this construction period, any assault can be deleterious (be it a viral infection, a chemical aggression or an inadequate nutrients supply). A chilo concieved perfectly healthy, can thus acquire physical or mental disalibilities in utero : post rubeolic malformations or neural tube defects like spina bifida or anenkephaly.
It follows that if a child is found carrier of an inborn anomaly, or of a developmental difficulty, its destiny can be predicted with an appreciable accuracy.

PREVENTION OR DESTRUCTION : QUO VADIS ?
Acquired abnormalities can be prevented : vaccination of young girls against rubella will protect the future babies and in the case of neural tube defects, the remarkable achievements of Smithells (1) has shown that folic acid given to the would be mother could diminish by a factor of ten, the risk of this disastrous malformation of the nervous systems.
On the same way, some exceptional cases of inborn errors can be adequatly managed in utero. For example, Methyl cobalamin deficiency can be compensated by vitaminotherapy of the pregnant mother (2) or, rhesus foeto maternal rncompatibility can be prevented by "vaccination" of an at risk mother or treated by exsanguino transfusion of the baby even in the womb.
But in the overwbelming majority of cases, no efficient protective answer is available.
Nowaday, amniocentesis, chorionic biopsy, or advanced imagery allow early detection of various afflictions, but the avowed purpose of these prenatal diagnosis is to eliminate by abortion the affected babies. Even in case of twin pregnancies, some have selectively killed the affected twin in utero (3) and in case of unwanted quintuplet pregnancy, have even killed by cardiac puncture three out of the five foetuses (4).
Health by death is a desperate mockery. The complete history of medicine is on hand to show that those who delivered humanity from plague and rabies were not those who burned the plague stricken alive in their houses or suffocated rabid patients between two mattresses. The only possible victory of medicine is over the disease, not over the patient.
Some technicians are even requesting the right to experiment on human embryos produced by in vitro fertilization. They say this will help them to understand, to prevent, and possibly cure very terrible genetic disabilities like hemophilia, muscular dystrophy, cystic fibrosis or Down's syndrome.
Three years ago I had the honor of explaining to members of the British Parliament that research on those diseases could not be performed at all on human embryos less than 14 days old for a very decisive reason : at this stage of development, the relevant organs (brain for mental retardation, pancreas for cystic fibrosis, muscle for muscular dystrophy, or blood-forming organs for hemophilia) are not yet developed.
Considered as a "french influence in Britain" (5) such a matter of fact statement was severly criticized by the promoters of experiments on human embryos. An appeal to embryologists (6) requested protocols showing convincingly that human embryos (no animal embryos) were absolutly requested.
Nearly there years later, no such protocol has been published !
On the contrary an advanced country, especially aware of the dangers of indulging experimentation on man, West Germany, is considering a law protecting the early human beings from any exploitation (7).
The very question is not to express a wish full statement that "embryo research may, in due course, enhance the same ideal, perhaps by helping to rid people of undignifying genetic diseases" (8) but to realise that we "are a long way from curing anyone of a genetic disease, but have already begun ridding ourselves of PEOPLE, with what we consider "undignifying genetic diseases", through abortion and euthanasia" (9).
Those recent quotations show how appropriate it is to ask Quo Vadis : where areth thou going ?
Should we accept the repeated leitmotiv that a full respect of the human nature is an out of fashion taboo and, frankly speaking, that moral is an impediment to discovery ? The very recent developments of molecular biology are confirming again and again that no good science has ever been builded on contempt of human dignity.
During the last three years, thanks to the work of many different researchers in many countries, the genes of cystic fibrosis (10) and of Duchenne's muscular dystrophy (11) have been found and cloned, as well as those of Huntington's Chorea (12) and of retinoblastoma (13). Even the specific protein of muscular dystrophy the "dystrophin" is now identified and analysed (14). For hemophilia, the special coagulation factor is now manufactured by manipulated bacterias so that patients can be treated with a pure product without any risk of transmission of AIDS through contaminated blood !
All these successes since 1985 have been obtained without endangering any human embryos at all. And none of the experiments were in contradiction with the absolute respect of each and every human being, from conception to natural death, which has always been the guideline of civilized scientists.
In this context, it is worth quoting the solemn declaration of 15 research workers of the Max Planck Institute "The abuse of these techniques through experiments with human embryos (or pre-embryos, if one considers a preimplantation embryo not to be an embryo) must be condemned by the scientific community" (15).
It is conforting that scientists living in a country in which the denatured biology at the nazis was once the legal doctrine, are thus restoring the dignity of biology as an honest servant of true medicine.

TOWARD A REHABILITATION MEDICINE
Two ways are broadly open : First the dechiphering of the abnormal gene products (like the dystrophin already quoted) will allow to understand their action and to find means of alleviating and even totally preventing their deleterious effects. This will be curative medicine of a very classical type even if highly sophisticated.
The second possibility could be, a direct correction of the bad gene. For instance a kind of "Magic Bullet" (a modified virus may be) could knock out the wrong genetic information and replace it by a correct segment of DNA. Although still very remote, this prospect is maybe not as far fetched as it could seem today.
These two procedures can be clearly envisaged for congenital abnormalities due to one mistake. But what about chromosomal errors where many genes (hundreds, thousands) are in fault or in excess ? The example of Down Syndrome to which I am particularly devoted will allow a short discussion of the state of affairs.
In this type of mental retardation affected children carry three chromosomes 21 instead of two normally. This trisomy 21 provokes a kind of "overdose" of genetic information.
The situation is roughly comparable to a car with a four cylinder engine mounted by mistake with five spark plugs ! Sure enough the motor would not run smoothly. A good car repairman, instead of throwing it away, (as an abo tionist would do), would delicately disconnect the extra spark plug and thus put the function back to normal.
We do not know yet how to unplug an extra chromosome, but nature does. She unplugs the extra X chromosomes when necessary. Maybe some day we will learn how to do it and apply the trick to the extra chromosome 21, responsible for the trisomy, the cause of Down's syndrome. Pending this "tour de force", yet to be invented, we can continue deciphering the genetic content of this chromosome. Already eight genes and multiple unnamed protein spots and scores of anonymous DNA segments are known. It is reasonable to suppose that in less than 10 years, the whole DNA of this chromosome will be unraveled. In the mean time, we can try to understand why and how the excess of the genes impair the functionning of nerves cells and prevent the full development of intellectual power. To keep the analogy with automobiles, we can look for some regulation of the "carbura-
tion" of the motor, so to speak.
It is already established that trisomic 21 children are more sensitive than normals to methotrexate (16). This anti-cancer drug interrupts the transport system of monocarbons, the small building blocks of important molecular edifices in the brain. This sensitivity can be demonstrated (17) in blood cells cultivated in vitro, and numerous other modifications of the culture medium are now feasible (18).
As curious as it could look, in vitro experimentation on cultivated cells, taken from a few drop of blood can allow a fine analysis of the genetical and biochemical troubles which provoke mental retardation or even psychiatric disorders. The mental retardation linked to the fragile-X condition, or to hypothyroidy are other examples of this type of investigations (19)(20).
Without going too deep in technical matters it can be predicted that various psychiatric syndromes (autism, Alzheimer-like deterioration) will be soon be studied experimentally in vitro, thank to these new procedures.
That is not to say that the destiny of these cheerful children will soon be allieviated although some medication trials are already attempted with interesting results (21)(22)(23)(24).
On the contrary, it means that important discoveries are just beginning and that respect for human nature does not impair research but stimulates it. The promoters of selective abortion, or of exploitation of human embryos were mistaken offering us this cruel dilemma : either you take part in this search and destroy mission and you accept the massacre of the innocents, or you refuse to help the families affected by incurable children and you wash your hands of their sorrow. No, medicine is not forced to choose between playing Herod or Pontius Pilate. It has to fight against the disease, not against the patient.
Nevertheless, in name of the technical progress, especially appointed "ethical" committees will possibly continue to try to blurr the moral judgment. But their contradictory oracles will never fully exorcize the sorrow, for a decisive reason : Technology is cumulative, wisdom is not.
When man himself is at stake the utmost wisdom is a moral principle, very simple and clear : "What you have done to the smallest of mine you have done it into Me".
If doctors always remember this word, the most sophisticated technique will remain the honest servant of rehabilitation medicine ; but if they forget it, then a denatured biology could never be rehabilitated.

References
(1) Smithells R.W., Nevin N.C., Seller M.J., Sheppard S., Harris R., Read A.I.,Fielding D.W., Walker S., Schorah C.J., Wild J. Further experience of vitamin supplementation for prevention of neural tube defect recurrences. Lancet i, 1983, 1027-1031.
(2) Rosenblatt D.S., Cooper B.A., Scmutz S.N., Zaleski W.A., Casezy R.E. Prenatal vitamin B12 therapy of a foetus with methycobalamin deficiency (Cobalamin E Disease). Lancet i, 1985, 1127-1129.
(3) Berg D., Baumgarther M., Doring K. Selective abortion of a twin with trisomy 21 via sectio parva in 23 pregnancy week and subsequent spontaneous birth of the healtly second twin. Geburtshilfe Frauenheil KD 1984,44, 563-565.
(4) Kanhai H.H.H., Van Rissel E.J.C., Meerman R.J., Gravenhorst J. Selective termination in quintuplet pregnancy during first trimester. Lancet i, 1986,1447.
(5) Walgate R. French influence in Britain. Nature 1985, 313, pp. 618.
(6) Editorial, Nature, An appeal to embryologist. Nature 1985, 314, pp. 11.
(7) Dickman S. Embryo research ban causes ructions in West Germany. Nature 1988, 333, 791.
(8) Editorial. Criminalizing research. Nature 1988, 333, pp. 787.
(9) Cochran K.W.M. German angle. Nature 1988, 334, pp. 560.
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TECHNOLOGY: CREATING NEW REALITIES

JOHN HUGHES
President of the International Society of Prosthetics and Orthotics, U.K.

Technology may be broadly defined as the application of science. The title of this presentation, therefore, suggests that the application of science is providing new real solutions in rehabilitation. While this is undoubtedly true, it is interesting to look at some of these solutions and ponder the problems of wide-spread provision. The examples used come from the field of prosthetics and orthotics, for, both in a professional capacity as Director of a major educational establishment in this field and as President of the International Society for Prosthetics and Orthotics, this is where the author's greatest involvement lies. The underlying principles, however, apply in all areas where technology impinges upon rehabilitation.

There is no coherent record of the development of prosthetic practice through the ages, but it is known that it was largely influenced by the surgeons, armourers and craftsmen involved, by the reasons for amputation and by the social conditions of the amputee.

Solutions for locomotor disabilities continued to be produced in much the same way as they had been for centuries right up to the early nineteen fifties - not as an application of science, but as an application of craft or art.

The first World War brought vast numbers of amputees and in many places a formalisation of these skills in the person of the artificial limb maker. The second World War again produced a sudden dramatic increase in the number of amputees. Few countries looked to more than increasing the output of their craft based industries. In the USA, however, with dissatisfaction about artificial limbs, their function and, their fit, some forward thinking administrators and clinicians decided to apply science to seek solutions. From this decision came the Fundamental Studies of Human Locomotion, carried out in the University of California, Berkeley (UCB). This was a landmark in this field, not because the studies actually provided the solutions, but because the technological approach had arrived.

The Fundamental Studies had as their aim the systematic study and quantification of the process of human locomotion. It was the first major work to analyse, albeit in a laborious way, the movements and the forces involved. Many sophisticated measurement systems are available now but probably never again will we persuade normal healthy students to take part in our experiments and have percutaneous pins screwed into their bony prominences to provide markers for the cine cameras! These were biomechanical studies - the study of forces and their effects on the human body. Prosthetics and orthotics had, therefore, become a branch of applied biomechanics - craft was giving way to science.

It must be said that the move from craft to science did not immediately revolutionise prosthetics and orthotics. Rather, a process started which, in the first developmental stages, examined and explained traditional approaches and permitted improvement.

An inevitable and necessary by-product of this change from craft to science was the change in the training and education of the prosthetist/orthotist. Instead of an emphasis on handcraft and improvisation, the requirement was for a science base - and the skills to translate a biomechanical analysis into an applied solution. A slow change from craft to vocational profession had started which, almost forty years later, is not yet universally applied.

New Technologies
One has the impression that in the ensuing twenty-odd years progress was very slow. However, it is certainly true that in the 80's, the evidence is that a rapidly increasing application of new technologies is displaying possibilities for improvement in patient treatment.

Materials: The structural elements of lower limb prostheses were traditionally metal or wood, reinforced, formerly with rawhide, and latterly with fibre glass/polyester or epoxy resin laminates. Such exoskeletal designs are now being replaced by so-called modular endoskeletal structures; systems of assembly from pre-manufactured standardised components, which after they have been provided and tried by the patient retain the facility for easy change of alignment, or change of components such as, for example, knee units or sockets. The use of carbon fibre has now produced designs which are stronger than traditional constructions and yet weigh as little as 2 Kg for an above-knee level prosthesis. When encompassed within a soft foam cover, these skeletal designs give prostheses which are strong, light, functional and cosmetic.

Carbon fibre also plays a part in new socket designs. Previously these were rigid containers of metal, wood or plastic. The use of a carbon fibre frame supporting a flexible polyethylene socket gives a comfortable, yielding, hygenic interface between the patient and the device which permits the transmission of force while adapting to change in stump shape due to muscle contraction.
New designs of so-called energy storing feet, such as the Seattle Foot, have only become possible because of the availability of a wide range of plastics, ranging from strong and rigid to soft and flexible. These designs provide function extending into sports activity, are virtually maintenance free and have a good cosmetic appearance.

Biomechanical design of the body/device interface: From the patient's point of view the most critical aspect of any device is the interface between him and the device. This is designed on a biomechanical basis. The procedure for any socket designed like this is the same - an analysis is carried out of the forces which will be developed between socket and stump in normal activity; the stump is examined to identify areas of pressure tolerance and sensitivity; the socket is designed so that it will transmit the forces, applying load to tolerant areas and reducing or relieving load on sensitive areas. In a practical sense this latter process involves taking a plaster of Paris wrap cast of the stump, pouring from this a male model of the stump, then removing plaster in areas of tolerance and adding plaster in areas of sensitivity. A socket formed over this "rectified" cast would selectively load and unload areas of the stump in a predetermined way. In this way combining scientific force analysis with the skills of the prosthetist, the belowknee amputee, for example, has very little loss of function indeed and using one of the modern self-suspending sockets very little impairment of cosmesis.

Computer technology now shows the promise of rationalising this procedure in such a way that the skills of the prosthetist may be "stored" and readily recalled by himself, or indeed any other trained operator. A typical computerised system of the present generation may use television cameras to measure the topography of the stump and a graphics processor to "operate" on the topography in a computerised equivalent of cast rectification to provide the design data for a functional socket. When this process is used as the feed for a numerically controlled carver, a model is produced from which a socket may rapidly be formed. This approach is currently being applied also to seating and to orthopaedic footwear. We in ISPO have just held (June '88) an international workshop on CAD/CAM which studied existing application and from which a number of research and evaluation projects will hopefully flow. The report of the workshop will be published later this year. The potential for revolutionising a vital area in rehabilitation technology is clear.

Force/Contro1 systems: One of the most exciting developing areas in orthotics is in the development of so-called hybrid orthoses which combine structural biomechanically designed orthoses with functional electrical stimulation in the treatment of patients with partial lesions of the spinal cord. Best known of these involves the reciprocal gait orthosis. Developed from an old design, but using new materials, this orthosis permits a reciprocal gait by stabailsing both knees and ankles/feet and linking hip movement in such a way that flexion of one hip is accompanied by extension of the other. When this is combined with phased stimulation of appropriate muscle groups, very significant gains in mobility are achieved by some patients. We are only starting to explore a myriad of possibilities presented by this hybrid approach.

These are only a few examples of what many of us perceive as an accelerating process of innovation and realisation. (I may mention that the 1989 World Congress of ISPO will be held in Kobe, Japan, and these and many other new advances will be presented and displayed in great detail in the conference and in the scientific and trade exhibitions.) The crucial question, however, is will realisation achieve the promise?

Realisation

It is apparent that even in the so-called developed world the variations in standards and levels of patient care in our field are very great. Our record in recognising and applying good new techniques is really very bad!

The problem is not usually straight-forward. If someone invents a new knee-control system, say, how do we know whether this represents a significant improvement in patient treatment or even just a useful addition to our armamentation of devices? If it is, how do we ensure that the good news is disseminated and that the new device finds wide-spread clinical application?
The first requirement is for an adequate evaluation programme - meaning a formalised procedure which permits new, good ideas to be identified and subjected to a controlled evaluation using agreed protocols so that its merits may be judged either against a set of criteria defining the aims of patient treatment, or in comparison to other devices or techniques said to fulfill the same function.

It is extraordinary how difficult it is to convince funding agencies of the value of spending money in this way in this particular field. Government departments which spend literally millions of pounds in paying for clinical treatment will typically spend next to nothing on evaluation of these treatments. And yet otherwise how can a decision be taken about an innovation in an efficient or meaningful way? Of course, the maximum benefit (in cost and other senses) would accrue if such evaluation programmes were organised on an international basis, or at least carried out to internationally agreed protocols so that the results of evaluation carried out by one agency could be accepted by another, thus saving cost to the individual nation. ISPO has tried over the last eighteen years to interest national and international agencies in such an organisation and coordination of effort with singular lack of success - astonishing when one considers the vast sums of money involved. Would a new drug be prescribed without first undergoing appropriate and stringent evaluation?

The second essential if successful innovation is to find general release into clinical practice is an adequate training structure - a system which provides formalized training for all members of the clinic team by means of structured courses in the new technique and which also ensures that any appropriate adjustments are made to the basic training. For example, as CAD/CAM becomes a reality, courses in the techniques involved will be required for established professionals, but also adjustments will be required in the undergraduate course in such areas as computer sciences.

It must be said that the single most important element in the "creation of new realities" in this field and in their widespread introduction is the education and training of the prosthetist/orthotist. In Scotland this is now an honours baccalaureate degree (equivalent, for example, to a Masters degree in the USA). I am convinced that the universal adoption of this level holds the greatest hope for the future. It is a scandal that still in some parts of the so-called developed world the tradesman of the last century can still be found dealing with patients.

The Developing Countries

It would be inappropriate at an international conference such as this, and even in a presentation concerned with advanced technology, to ignore that part of the world which is not yet in a position to afford the technologies we are considering.

For many years international agencies which should have known better, regarded prosthetics and orthotics as a luxury beyond the reach of most developing countries. This condemned to despair such as the 2.5 million sufferers from poliomyelitis, a disease which we no longer encounter, and the 11 or 12 million leprosy patients. Happily that attitude is changing, but unless great care is exercised, much effort will be wasted in achieving an inadequate result. The catch phrase applied to the developing world is "appropriate technology". This must not be interpreted as meaning "primitive technology" and left to the well-meaning amateurs who are not professionally qualified to recognise what is appropriate. Appropriate devices use locally available materials and crafts, but still apply biomechanical solutions based on known prosthetics/orthotics techniques. The education and training of the prosthetist/orthotist may not yet reach our level, but should be at least as high as other paramedical workers. Various recent estimates identify a need to train perhaps as many as 50,000 to 100,000 skilled workers for the developing world. Those of us who belong to responsible agencies have a duty to influence progress in the developing world and to do it with careful planning from an informed base. It is only in this way that countless millions have any hope of being restored to a gainful, respected and dignified, place in the community.

ROBOTICS AND REHABILITATION

ICHIRO KATO
Department of Mechanical Engineering, Waseda University, Tokyo, Japan

The progress of robots used for production are producing a large technical influence on medical treatment and welfare. Robots are playing the role of assistants in medical education and treatment, or the complementary role of supporting physical functions in rehabilitation facilities. Let's now take a look at how such robots are being used.

1. Patient Robots
While industrial robots perform the role of producing something, medical robots are simulators that play a passive role, and are used in educational programs for physicians and nurses. These medical robots are called patient simulators.
There is another type of simulator robot, called a dummy robot, which is placed in a can to collect data on the possible damage which human passengers might suffer in an accident of automobile collision. The patient robot shares the same concept.
The first patient robot was an education robot for anesthesia developed by the University of Southern California. Called SIM-1 (meaning simulator No. 1), this robot was designed for use as an educational model to show young physicians and nurses how anesthesia should be administered to patients before surgery.
First, the condition of a patient and the surgery to be performed are shown to the students, who then determine the kind of anesthesia to be administered to the patient. When an action corresponding to administering anesthesia is taken, the robot that is connected to a computer reacts to the anesthesia, showing a rise in the palpitation of the heart or a rough breath. The computer outputs the data which show whether the action that has just been taken is corrcct.
This simulator robot also shows change in blood pressure, reaction of the pupil, etc. and, if an intravenous drip injection is administered, allows monitoring of the reaction of a living body. Patient simulators for the blood circulatory system were also developed in the United States.
In Japan, a training robot for briging drowned persons to life again was developed by a group of Tokyo Women's Medical College. The robot has reactive mechanisms responding to a heart massage or mouth-to-mouth breath, showing restoration to the normal pulse and normal blood pressure, or to normal reaction of the pupil, or to a regular heart beat. This robot is also connected to a computer to give data in numerical values.
The monitor displays the condition of the patient and the instructions to'the students, such as "Blood not circulating enough," "Massage more correctly," and "Breath not enough." The training results can be confirmed again with recordings on paper.

2. Diagnostic Robots
Robots are also being used for medical diagnostic purposes. Apart from many electromechanical devices, such as CT scanners and ultrasonic appliances, that are used as auxiliary tools of diagnosis, diagnostic robots are emerging.
A breast cancer palpation is one of such diagnoses. The most typical method of breast cancer diagnosis is palpation by a physicin using five fingers. In addition to it, X-ray or ultrasonic image diagnosis is used as an auxiliary means.
The study of a palpation robot aims at acquiring data from the robot touching the breasts as if the doctor does with his five fingers, and making decisions with its mechanical brain serving as a substitute for the brains of a physician.
The physician acquires various kinds of information using his five fingers. Such information may include the size, position, hardness, contours, and mobility of tumor. These quantity data are qualitatively judged by his brains to make a decision whether the breast tumor is malignant or not.
The robot's hand will imitate exactly the way of breast diagnosis by a physician. The artificial fingers of the robot have two types of sensors, one for sensing position and the other for sensing force. Several fingers with these sensors simultaneously press the breasts, and send information to the computer.
The human being has only five fingers on one hand, and use them for diagnosis. But the advantage is that the human being has almost countless 'sensors" under the skin.
Machine fingers, however, cannot have so many sensors built into them. One mechanical finger can have just one sensor. If possible, a robot having as many fingers as 'human sensors" is desirable. But this is still remote from a reality. Therefore, a limited number of fingers will be used to press the breasts several times to acquire information. This will produce an effect equivalent to the case of using multiple sensors.
Because of the present technical limitations, the form and the way of acquiring information are different from the case of diagnosis by physicians. The robot will process information in essentially the same way as man does. The robot learns the way physicians make decisions from the data with their brains, and uses a computer to do it.
The scope of applications of this technique to robots will widen if this kind of sensing - acquiring information - becomes a reality.
As mentioned before, only one kind of information can be acquired at one point. This breast cancer diagnostic robot capable of acquiring information similar to that acquired by examination using the human senses and making decision on the basis of that information signifies the development of a powerful tool for providing robots with advanced intelligence.
The present robots for industrial use perform work only on hardware, that is, materials and machines. But robots will then be able to work on not only hardware but also human beings.
One of the fields where such robots will be usable is medicine. Another is rehabilitation. Future robots may also be used at home to help sick or old people. The technique of the breast cancer diagnostic robot will be basic and important, opening the way to application to one field after another. It will provide basic know-how for developing what may be called a home robot or a personal robot which will be used at home to help sick or old people.
This diagnostic robot has nearly reached the level of practical usefulness. The technique of this robot that has been developed so far carries an important meaning as a basic technique to develop artificial senses close to those of the human being, which future robots must have.

3. Tender Robots
Tender robots which will directly help the sick are being developed.
Patients who have just been operated on and old sick persons who have to stay in bed need the help of some one else. The illness may cause any change in their physical condition or raise physiological needs anytime. So, some one must always be there to help the patient. The fact, however, is that this kind of service is getting increasingly difficult to expect. There are anticipations, therefore, that tender robots will be available to help patients and sick old persons.
Tender robots may be required to have functions similar to those of ordinary industrial robots in some cases. To help a sick person lying in bed drink something, for exampl, the robot needs to handle only hardware, that is, a glass. That kind of technique has already been developed for industrial robots.
When it comes to do something more complex, however, problems may occur. For example, a person lying in bed may have to be taken up in the arms from the bed and moved to a wheelchair. Or, a sick person may need help in taking a bath. In such cases, a human helper carefully holds and helps the sick one making full use of the senses of the skin. If a robot tries to do it with its hard mechanical hands, the sick person could be injured.
Therefore, robots for these purposes must have senses similar to those of the human skin, which the breast cancer diagnostic robot has in the form of artificial fingers.
A system now in the process of development uses a cushion and extends two arms under it to hold a patient up.

4. Welfare Robots
Attention is paid to robots which will help physically handicapped people in many ways.
Guide dogs, for example, help those who cannot see. A guide robot to substitute guide dogs is being developed. It is a system which transmits information as signals by electric stimulation from an electrode box, to be hand-held by a visually handicapped person, to guide him or her.
A motor-driven wheelchair of high performance is also under development for disabled persons. It allows them to freely operate the wheelchair using functions other than the limbs. Manipulators are provided on the wheelchair, and commands are transmitted by movements of the jaws or by voice to move or manipulate the wheelchair.
Robot technology is also applied to artificial hands and legs for those who lost them.
Artificial hands and legs of an electromyogram controlled system now available can be used in the same way as human hands and legs. As a command is transmitted from the brains via the motor nerves to the muscles, the muscles contract to move the hands or legs. Artificial hands and legs of the electromyogram controlled system are based on the same theory.
An electrode is placed on the skin of a limb extremity to receive a command transmitted via the motor nerves. The command is interpreted by a small electronic circuit - a kind of computer - and the artifical hands or legs are driven according to the meaning of the electronic signal deciphered.
Some robots have a sensing device in an artificial hand. The human hands and legs have cutaneous sensation, and feed back information on the objects they touch via the sensory nerves to the brains. These robots work in a similar way. When the artificial hand touches something, the sensing device built in the hand converts the information into electrical signals to be transmitted via the electrode placed on the skin at the extremity of the hand to the sensory nerves and to the brains, where a decision is made according to the electrical signals received. Different from the conventional type of artificial hand which opens or closes the fingers using the force of body muscles, this type of artificial hand can be directly used almost in a natural way without long training.
If this electromyogram controlled system is applied to an artificial leg, walking speed can be automatically changed, or a stairway may be walked up or down using the artificial leg and the natural leg alternately - in the same way non-handicapped persons do.
This kind of system requires large power. One system uses a device of generating and storing power, implanted in the ankle of an artificial leg. When the wearer walks, the device generates energy from the rotary motion of the ankle in the walking direction, and stores that energy to drive the knee.

5. Social Problems of Welfare Appliances
Different from medical apparatus, these welfare machines involve large problems. CT scanners, for example, are used four times as many in Japan as in the United States in the population ratio thanks to the national medical insurance system. In terms of actual quantity, Japan has twice as many CT scanners as the United States. Welfare machines, however, are not always supported by an insurance system. This is a problem for those who need welfare machines. There is another big problem that lies till welfare machines good for practical usefulness can be made available. Even though the feasibility of a welfare machine is basically proved in the research stage, considerable efforts involving a field test and others will be needed before the machine is actually delivered to the ones who need it.
Different from machines for industrial purposes, welfare machines will not used in large quantities so that their prices will be inevitably very high. Welfare robots are industrial products so that, if there is a large demand for them, their price could be lowered. But an advanced society does not always have a large demand for welfare machines. Because an advanced society is what we aim at, the price problem will pose a dilemma.

[References]
(1) I.Kato,"The 3RD MACHINE - PERSONAL ROBOTS -", 15th International Symposium on Industrial Robots(ISIR),Tokyo Japan,1985
(2) K.Koganezawa and I.Kato, "CONTROL ASPECTS OF ARTIFICIAL LEG", CONTROL ASPECTS OF BIOMEDICAL ENGINEERING, IFAC, PERGAMON PRESS,1987
(3) I.Kato,"21st CENTURY DEVELOPED BY ROBOTS",5th International Symposium on Robotics in Construction(ISRC), Tokyo Japan, 1988

Title:
16th World Congress of Rehabilitation International No.3 P.99-P.135

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

Month,Year of Publication:
Jun,1989

To access/retrieve this document:
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Phone:03-5273-0601 Fax:03-5273-1523