On-line version ISSN 0038-2337
S. Afr. j. occup. ther. vol.45 n.3 Pretoria Dec. 2015
Tshinetise Alfred Ramukumba
IB. OT (MEDUNSA); Associate Professor and HOD Occupational Therapy, Sefako Makgatho Health Sciences University
IIAdult Education & Training (RAU); Associate Professor and HOD Occupational Therapy, Sefako Makgatho Health Sciences University
This lecture aims to acknowledge both individual and collective professional achievements by occupational therapists in South Africa. It highlights specific work done which contributes to the development of occupational therapy nationally and internationally. In line with the Congress theme, "Rooted in Africa: diverse realities and possibilities", it acknowledges the diverse realities and contexts in which occupational therapy is practised particularly in developing countries. The transformation process that is taking place in South Africa seems to be focussing on politics rather than on the economic needs of the majority of the population which result from poverty and unemployment. The lecture proposes that occupational therapists should prioritise economic occupations which could lead to greater economic freedom and empowerment of clients and their communities.
Key words: Economic occupations, transformation, diverse realities and contexts, individual and collective professional achievements
It is a privilege and an honour for me to receive the 2014 Vona du Toit Memorial Lecture Award. Delivering the 23rd Memorial Lecture offers an opportunity to share my thoughts about the direction in which the profession should be moving more than 20 years since South Africa's democratic government was voted into power.
Contribution to the development of occupational therapy
I never had the opportunity to meet the late Vona du Toit, but I believe that I understand what she stood for in the profession of occupational therapy. Irrespective of the demands of her work as the Principal of the Pretoria College of Occupational Therapy and as head of the clinical services section at the H.F. Verwoerd Hospital1, she managed to present numerous papers at national and international congresses. She also went a step further than most of us by developing what is commonly known as the Vona du Toit Theory of Creative Ability. This theory and supporting papers have been posthumously published in the book, "Patient Volition and Action in Occupational Therapy"1. Well known South African occupational therapists like Dain van der Reyden and Pat de Witt have published book chapters and/or journal articles centred on the theory2,3. In addition, since 2008/2009 the Theory of Creative Ability has been strongly promoted in the United Kingdom under the leadership of Wendy Sherwood and in Japan under the leadership of Yoshiko Nakano and Mengumi Sato4. The theory is also being further developed through ongoing research - for example, Daleen Casteleijn recently analysed Vona du Toit's theoretical assumptions, concepts and constructs in a 2013 journal article published in the South African Journal of Occupational Therapy5.
Another of Vona du Toit's achievements was that, she was one of only three South African occupational therapists to have served as members of the Executive Committee of the World Federation of Occupational Therapists (WFOT). She and Rosemary Crouch served WFOT as vice-presidents, while I have had the honour to serve as a WFOT Education and Research Programme Coordinator.
I am convinced that Vona du Toit was always determined to champion the development of OT as a profession, even though the period during which she developed her theory (i.e. from 1962 onwards) would have coincided with the threat of international isolation due to apartheid and this may have impacted negatively on international recognition of her work. As pointed out in the submission made by the Occupational Therapy Association of South Africa (OTASA) to the Truth and Reconciliation Commission (TRC), from I960 to 1994 South African therapists faced threats of being excluded from the WFOT6.
It is thus fitting that we have gathered here today to remember and celebrate the contributions Vona du Toit made to the development of occupational therapy in South Africa and - even after her death - to the world-wide development of our profession. OTASA and the Vona and Marie Du Toit Foundation need to be commended for keeping her memory alive and her work ongoing. The value of celebrating our individual and collective professional achievements cannot easily be measured and should not be undermined.
Diverse contexts and realities
The Congress theme, "Rooted in Africa: diverse realities and possibilities", challenges us to reflect on our continent which is characterised by widely divergent realities and contexts7. Understanding the history of South Africa and the impacts of the apartheid laws leads to a full appreciation of the diverse realities and contexts that characterise our country today8,9,I0.
The key note address that I gave at the 2002 WFOT Congress in Sweden11 focussed on the realities of classical Third World living conditions experienced by those of poor socioeconomic status, which stand in stark contrast to the much better socioeconomic status and living conditions experienced by those in the First World. During this key note address, I commented that even though South Africa's democratically elected government has brought about political changes, there are areas in which progress is very slow or non-existent. In particular, we have made little progress in relation to "economic freedom, poverty eradication and land ownership"11:40. There is a tendency to consider South Africa as offering better livelihoods for its citizens than the realities which prevail in other African countries. Nevertheless, it must be noted that around 14% of the population still live in informal dwellings and 7% in traditional dwellings12 and access to services remains a challenge particularly for people in these categories. Increases in the cost of living have also significantly worsened the living conditions of the poor. In my view, these realities can be addressed by a common solution, namely finding the economic means/capital to change the lives of the majority of the population. This is in line with Maslow's Hierarchy of Needs13:286, which is familiar to occupational therapists and reflects that "low needs must be at least partially satisfied before needs that are higher in hierarchy become important sources of motivation"13:286. Thus, satisfaction of lower-order needs such as physiological and safety needs should precede higher-order needs such as social, ego and self-actualisation. We must ask ourselves, in this context, whether our occupational therapy philosophy fully addresses the areas of occupation which can satisfy clients' economic needs - the foundation upon which all other needs rest. For instance, when basic needs are not satisfied preference in OT intervention programmes should not be given to improving clients' participation in leisure activities - this is simply unworkable.
In developing countries like South Africa in which poverty remains one of the biggest challenges, we must reflect on our professional stance and focus and identify possibilities for making a difference and changing the lives of the majority of the population. Hence the topic of my lecture, "Economic Occupations: The 'hidden key' to transformation".
The impact of poverty
Barker14 defines poverty as the state of being poor or deficient in money or means of subsistence. In South Africa, 41% of our population of 51.7 million people live under the poverty line12. The South African Government National Planning Commission acknowledges that:
"Poverty has many dimensions that shape people's lives. Poverty in South Africa is most evident in the lack of opportunities for economically active citizens to earn a wage. Income poverty affects individuals and households in ways that are often degrading and leads to precarious lifestyles .... Without access to quality health and education and income-earning opportunities, the lives of the vast majority of the poor wage a daily struggle to simply survive" l5:6.
Fourie, Galvaan and Beeton16:70 have pointed out that "poverty has a devastating effect on occupational potential" in that it influences choices of occupations and restricts opportunities for participation. The 2001 World Bank Report17 presents a multi-dimensional view of poverty - for instance, one must consider issues of material poverty, chronic poverty, intergenerational poverty and poverty of the capacity to aspire. The first - and most important - of the Millennium Development Goals18 is "Eradicating Extreme Hunger and Poverty", and WFOT's19 priorities for 2007 - 2012 include occupational therapists and occupational therapy associations supporting the Millennium Development Goals. Similarly, Fourie, et al 16:83 propose that "all occupational therapists - even those working with individuals in conventional clinical practice - need to keep in mind the issues raised by poverty for most people in the world".
Thus, both individually and collectively we need to embark on a new agenda and adopt a new vision regarding the use of occupations in our clients' lives. This implies a need to obtain knowledge and learn strategies, so that we can improve much needed resources. Before talking about the new vision, I would like to commend several authors of books, chapters and journal articles who have captured the practice of occupational therapy in Africa, particularly in South Africa. Their writing highlights the challenges resulting from diverse contexts and suggests solutions to address such challenges. I must make mention of Watson and Swartz20 for "Transformation through Occupation", Crouch and Alers21 for "Occupational Therapy in Psychiatry and Mental Health" and Alers and Crouch22 for "Occupational therapy: an African perspective", and Lorenzo, Duncan, Buchanan and Alsop23 for "Practice and Service Learning in Occupational Therapy". Furthermore, I commend Kronenberg, Pollard & Sakellariou24 for "Occupational Therapies Without Borders" as well as my fellow authors Asaba, Lesunyane and Wong25 with whom I wrote "Globalization and Occupation: A perspective from Japan, South Africa, and Hong Kong".
We must acknowledge, as did Crouch26:107 in 2010 that some African countries' resources "are being used in an attempt to alleviate poverty and to improve the quality of life by adequately satisfying fundamental human needs and by creating a difference", and indeed many articles on this subject have been published in the South African Journal of Occupational Therapy (SAJOT). However, each time I reflect on the contribution the occupational therapy profession is making in improving our clients' livelihoods, I realise that different approaches are necessary. We need to ask ourselves whether our profession is contributing maximally to community development and the transformation process. If not, we need a new vision regarding the use of occupations in a way which empowers individuals and communities, within our intervention strategies.
Ikiugu27:120 argues that "occupational therapists can contribute their knowledge of human occupation and occupational performance to help illuminate wider societal occupation-related challenges". There has been a consistent and shared vision regarding the use of occupation by occupational therapists over the years. However, Duncan28:22 points out that the paradigm of occupation has evolved over time. Thus, from 1900 to the 1940s occupation was seen as being "essential to life and having an influence on peoples' health", from the 1940s to the 1980s the focus was on the functioning of the inner systems (intra-psychic, nervous and musculoskeletal) which led to occupational therapy adopting biomedical explanations and approaches to dysfunction. Since the 1980s occupation was perceived as having "a central role in human life by providing motive and meaning". Recent understandings place greater emphasis on access to occupations and their impact on quality of life28. In my opinion, this evolution has addressed the needs of society/communities at different periods of time. In post-1994 South Africa many of us hoped that, as part of the transformation process, the democratic government would address occupational risk factors such as Wilcock's29 occupational imbalance, deprivation, alienation, insufficiency and injustice. However, my observations lead me to conclude that not much has changed for those who were historically disadvantaged. For this reason, occupational therapists have to 'think out of the box' and stop what is commonly referred to as 'business as usual'.
I propose that we should prioritise economic occupations. Participation in occupation which results in economic freedom could in turn, lead our clients to peace of mind and happiness. This proposal is in no way intended to challenge the acknowledged/ accepted philosophy of occupational therapy and the use of occupation to promote health and wellbeing30 or to bring meaning to an individual's life31. However, I am convinced that we need a paradigm shift as a profession, such that we prioritise economic occupations. This will be in line with what Estelle Shipham expressed in the nineties in her Vona du Toit Memorial Lecture. She stated that, "...the integral part of health care needs (in South Africa) are to be achieved through empowerment and development of individuals and their communities towards real independence - especially economic independence"32
Occupational therapy as a profession makes use of elusive, philosophical concepts and the challenge is that occupational therapists themselves often disagree on the meaning of these concepts. A good example is our usage of the word 'activities' versus the word 'occupations'. Complicating the situation, therapists differ in their first language, and may struggle to explain the differences between activities and occupations to clients from the various South African language groups. Those involved in teaching students who do not have English as their home language will fully understand the challenges to which I refer. It has been proposed that quality of life and meaningful occupations are the core of occupational therapy33, but do these mean the same thing in different contexts? Similarly, concepts such as 'occupational justice' need to be viewed differently within different contexts. How then, should our professional philosophy accommodate these different meanings?
My own experiences reflect what authors have noted; regarding the value that meaningful occupations play in people's lives (see for instance De Witt34; Watson & Fourie35; and Christiansen & Townsend31). Often when life seemed to lack meaning, I have used occupations to bring meaning in my own life. I have also counselled family members, students and colleagues to use occupations to cope with life challenges and make their lives more meaningful, and the feedback I have received has always been very positive. Nevertheless, I believe that we must use a different approach when prioritising occupations, not just focussing on their meaning but also focusing on how they can address the needs of poor communities.
My reflections on the current realities of South Africa indicate that the transformation which has taken place since 1994 has taken place mainly at a social level and not at the level of communities and individuals. As a profession, how do we focus on empowering and addressing the needs of the majority of our population who live in poverty and are unemployed? What do we do to ensure improvement in their quality of life and create opportunities for them to engage in meaningful occupations? Watson36:51 pointed out that "... reawakening of possibility for development may lead to transformation - enriching and redirecting lives". Yet how do we ensure that the process of transformation remains a priority for the poor and the marginalised who need it most? How do we empower individuals and communities, and develop and implement projects that could lead to economic independence? Transformation must include addressing the impact of deprivation by increasing productivity and empowerment36:51, and this requires strategising to address barriers to individuals' economic independence. Such barriers include limited employment opportunities and lack of skills, training and experience. We must address these in order to keep the transformation process ongoing.
Thus, occupational therapy as a profession should look at different ways of approaching or utilising occupations, to facilitate, maintain and transform the lives of our poor communities. A paradigm shift is needed, so that we can change people's livelihoods in a valid manner - in this way, we will be seen to make a difference.
Charity and hand-outs should only be temporary measures, NOT a way of life as they have become in some developing countries like South Africa. Occupational therapists should heed the view of the Greek physician Galen (172 AD), namely that "Employment is nature's best physician and is essential to human happiness"37:91.
Hence my proposal to the profession is that of a shift from an emphasis on employment of disabled to emphasis on employment (in income generating occupations) for all who are at risk of poverty which poses a threat to their health.
A CASE STUDY
To illustrate my proposal I will share with you the case of Mr A, aged 33. He was single and unemployed and lived with his parents and younger sister about two kilometres from the local hospital. He was diagnosed with Bipolar Mood Disorder and attended monthly treatment reviews, and at the time of my first meeting with him he had recently relapsed and was hospitalised. On assessment I found him to come across as very intelligent and motivated, with intellectual insight. His main concerns about his illness centred on stigma and isolation from his community - neighbours laughing at him left him feeling rejected, which contributed to his frequent relapses.
Two weeks after starting occupational therapy he was discharged and arrangements were made for him to continue with outpatient therapy on a daily basis. Through this, an opportunity was created for him to run a shoe repairing project, and he was able to generate income so that he could buy more materials and continue with the project. During a follow-up interview he revealed that his community thought that he was working full time in the hospital and as such showed respect to him. He was better accepted by his community and became a proud and happy man as a result of using occupations that were of value to him and brought meaning to his life when relating with his community.
Economic occupations and the "hidden key"
I am not viewing Mr A's case study in a simplistic manner. Like each of us, he is an occupational being38 who should engage in occupation to find meaning and purpose39. At the same time, occupation can improve health and wellbeing31 and restore occupational balance40. Meaningful occupations must be seen from an economic point of view, in relation to those who are underprivileged.
Developing countries like South Africa face the reality of diverse contexts characterised by communities with varied economic challenges. Whereas multiple factors influence occupational choices and availability of resources, including culture and poor economic conditions often lead to individuals opting specifically for paid occupations, which may not be to their liking, in order to survive25,31. As Crouch22:53 states, "The value of the occupation will depend on the needs of the person and the needs of those in the social structure ...". Western views of life and health have undoubtedly influenced the focus of occupational therapy as a profession, and I believe that our philosophy and focus will be different when we address the needs of communities in developing countries.
The choice of occupations depends on biological, psychological and contextual factors31, but we have previously argued25 that the influence of each type of factor depends on specific communities and individuals. Economic factors within an individual's context tend to determine the degree to which other factors impact on choice of occupation. Thus, where economic issues are less critical, the other factors can play a greater role. Bührmann41:24 notes that to appreciate what influences occupational choices, one needs to "understand, respectfully or enter in the inner world of another". Yet, "the African continent is in a ... dilemma because of (the) extreme pressure on its black inhabitants to develop a Western-originated society, a Western type of ego consciousness with Western goals and measures of achievement"41:100. Undoubtedly, the inner world of the majority of the population in South Africa is clouded by poverty and poor socio-economic conditions and income generation is viewed as a priority. Despite their harsh realities, both urban and rural South African communities strive to improve their lives by seeking employment and participating in income generating projects25:397. Arguably, then, some of the communities in which occupational therapists render services lack the luxury of free occupational choice. Yet my argument is that by addressing such communities' economic challenges we actually enable them to choose meaningful occupations.
Metaphorically, the 'hidden key' which we can use as occupational therapists is the application of our creative thinking to select and make recommendations in relation to economic occupations. We can advocate for and initiate and develop strategies that lead to sustainable economic empowerment, placing us amongst the professions which can make a difference in implementation of strategies to improve income generation for individuals living in poverty and consequently at risk of ill health. I believe that the use of economic occupations to address basic needs can address the occupational risks which tend to produce ill health and dysfunction in poor communities. Baum42::XV reminds occupational therapists that the public usually thinks of work when we talk about occupations, and notes that occupational therapists are "asked to respond and act on the needs of the society through the healthcare systems and community systems". We are well equipped to embark on a drive to create occupational empowerment43 on a larger scale, yet we have not explored community systems enough and even when we are aware of the needs we are not committed to this approach. As a profession, we tend to focus on approaches tried and tested in developed countries whose populations have completely different needs. Economic occupations are 'a hidden key' (a solution; the answer) which we can utilise to foster real transformation. A focus on such occupations is in line with the OTASA definition of occupational therapy, as published on SAJOT44. This definition makes it clear that we are bound as a profession to address the needs of ALL individuals and communities (living with disabilities or not) who are occupationally dysfunctional. As noted in a Special Edition on Human Rights45, published by SAJOT in 20I0, the United Nation Convention on the Rights of Persons with Disabilities includes the right to access rehabilitation. We as occupational therapists are well placed to promote the rights of persons with disabilities, particularly those related to education; habilitation and rehabilitation; work and employment.
In closing, I believe that it is essential that the profession should position itself so as to partner with government, non-governmental organisations and businesses to create opportunities and possibilities for our clients to become economically independent. This implies a need for greater training in the field of work, as part of our undergraduate curriculum and including the use of traditional and cultural activities as a means of earning a livelihood. Training centers need to review their curriculum in order to consider inclusion of these suggestions. While clients should have full ownership of the process, occupational therapists can serve as a link between them and their communities. In this way, we can empower individuals and focus on economic occupations in settings such as, income generating projects, farming/agriculture and businesses (including service businesses such as cleaning and gardening).
I would like to conclude by quoting Ruth Watson46:13, who noted that "the value and power of an appropriate occupational therapy approach lies in its sensitivity and responsiveness to clients' expressed needs, and not in the therapist's assumptions". As we adopt a new agenda, develop new strategies and utilise occupations to empower our clients and their communities, let us find out directly from them what their priority needs are.
I dedicate this paper to my family, friends and colleagues for their support throughout my career.
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Tshinetise Alfred Ramukumba
Occupational Therapy Department
Sefako Makgatho Health Sciences University
Box 158, MEDUNSA. 0204