Getting Community Based Rehabilitation started in rural Botswana

(Excerpted from Memories that Linger: My journey in the Word f Disability by Padmani Mendis)

The first group we visited wished to go together to the home of Ntchadi. Before we went to her home, the FWEs (Family Welfare Educators) told me that she had difficulty moving from place to place. She was about 10 years old. They said they wished they could do something for her. She had a very large head. She could not stand up because, they thought, she could not carry the weight of her head. I could see that she had hydrocephalus.

We visited Ntchadi’s home and were invited to sit on the bench outside the door. All the homes in the villages of Botswana were round mud huts. All the family members slept on mats which they would spread out on the floor at night. It was seldom that strangers were asked inside a home. We used the space available on the bench which was always to be found outside the door, while others stood by, leaning against the house or against a post. Ntchadi came close and sat on her haunches ready to join the conversation.

We talked with the mother about all her children until we came to Ntchadi. Her mother told us that Ntchadi wanted to go school. We asked Ntchadi whether she did and why, what she would do at school, did she have any friends and so on. She replied hesitantly and shyly. The mother added that Ntchadi stood at the fence to watch with a sad face as her brothers and sisters left for school. She would stand at the fence later when they were due back.

Ethel asked the group what we should do. “Shall we go and ask the school principal?” SSO (Social Servce Officer) Chele suggested. We asked Ntchadi and her mother whether they would like to do that. “But how can she go to school?” the mother asked. I stepped in say let’s go and ask the principal as Chele suggested.

It turned out the school was just opposite Ntchadi’s home. Chele went across, met the principal and asked him if he could meet us. We all walked across in a group to the school. The school was also made of small mud buildings. The principal, looking pleasant and stern at the same time, said first that he did not know that Ntchadi wanted to come to his school. He said now that he knew she did, of course she could.

At which Ntchadi’s face broke into a smile. SSO Joyce had questions. But how could she get here and back? What if she wanted to use the toilet? The principal replied that he had a wheelbarrow, and would ask children to take turns to fetch Ntchadi and take her back. And if she needed to use the toilet, someone will take her home in the wheelbarrow, he said.

There was a single neurosurgical specialist at the General Hospital in Gaborone, and a single physiotherapist. Where is the access to hospitals, specialised medical treatment and rehabilitation in countries such as these? Were these FWEs then delivering a cheap, low-cost service? Was this improving the quality of life of a child or not? Was this the medical model of rehabilitation? Or was it a developmental model? A rights-based model? Equal access to all or to the privileged few? To whatever questions critics had, this was CBR.

I heard that later the principal was a member of the Rehabilitation Committee Chele had helped their Kgotla or Village Chief to set up. Chele was happy with the interest the committee showed in their disabled people and with the support she got from them. The FWEs learned from this example that sometimes the solution lay within themselves.

Another group of FWEs took us to visit the home of three-year old Kealoboga. Ethel helped the FWEs assess her using Forms from the Manual. They found she could not sit by herself and she could not speak. They decided to teach the mother to use the Package on Play Activities to stimulate Kealoboga’s development. We went with Kealoboga and her mother to the village store and with difficulty got a cardboard box. Even a small box was a scarce resource in the village. The FWEs made some adjustments so that Kealoboga could sit in the box. They showed her mother how to speak to Kealoboga in the way that was shown in the Manual.

Not having the Manual in Setswana made it difficult for the families. Plans had already been made by Adelaide to have it translated. Funds were available, but the translation was taking a long time.

Family Welfare Educators

FWEs were the community health workers. They had a basic education, were full-time workers and came from the villages they worked in. The ones in our group of 15 were in the age group of perhaps 22 – 35 years. They were paid workers. After their field training was over, they told me they would visit the homes of the disabled members when they visited that part of the village for other reasons. In other words, they planned to integrate this task together with others they did in Primary Health Care.

And so we continued from day to day. When we needed a break for lunch we would find a bench to sit on quite close to a village store. FWEs and Ethel brought their own lunch. I would have an oil cake and a coke from the store. I disliked coke intensely, just for the brand name. But most often it was all the small store had. Home-made fresh oil cakes with coke which was probably from South Africa. That country was the source of all imports. Boy, did that white minority exploit their neighbours?

Over our lunch break the FWEs had lots of questions for me of a personal nature. One thing that seemed to fascinate many of them was my complexion. They commented on how smooth it was, and asked what I used. They were surprised when I said I used Nivea occasionally, just to prevent my skin from dryness. I was only forty years of age then. The wrinkles appeared three decades later. And the grey hairs took another decade.

The FWEs told me that most people living in Serowe were from the Bamangwato tribe. Each Motswana family had three homes. Now that they had regular jobs they themselves had to remain in Serowe all through the year. But some of their family when the rains came, had to spend time on their family lands and cultivate their fields. And then they went to the grazing areas or cattle posts to tend to their cattle. But every family was required to spend some time of the year in Serowe itself. They agreed with the chief that this was necessary to maintain tribal unity. They all spoke Setswana at home. At school they had studied in English.

Ethel Matiza

Ethel, always with a beaming smile on her face, always presenting an appearance of not having a care in the world. But there were times, and quite often too, that I caught in her eyes signs of desperation, of a deep unhappiness. In time I found out she had good reason for this. Ethel called herself a refugee from what was then Southern Rhodesia, now Zimbabwe. Southern Rhodesia had a white minority government dominating the black majority. You may remember Ian Smith the white prime minister? The black majority were being discriminated against, segregated and exploited as they were in South Africa.

The majority were struggling for their right to govern their country. Ethel told me this struggle was becoming increasingly violent. Her husband was actively involved in the struggle and his whole family was in danger of persecution. So much so her family believed it was safer for them to take refuge in Botswana. She was here with her parents and two children. Her husband continued to be a leader in the freedom movement. She was very afraid for him. This is the unhappiness, the desperation that I was seeing in her eyes. She told me that she thought their struggle would soon be over, but she still worried.

I heard early the following year that Zimbabwe finally gained its independence from Britain. It was of course world news. I was happy that Ethel could return home with her family and be safe with her husband. I knew at the same time that her going home will be a loss to the disabled people in Serowe, and indeed to Botswana. She was a dedicated worker with immense potential. She too, believed that CBR was the way forward.

The Serowe Hotel

The Serowe Hotel was situated on the Serowe-Palapye Road. The latter was then an important junction for both road and train travel. The distance between Palapye and Serowe was almost fifty kilometres. The road had been built only over ten years ago, so development alongside was recent. The Serowe Hotel was situated just inside the outer boundary of Serowe. From its appearance one would not have thought that it had been built within the last decade.

The hotel was a very small building. Two bedrooms for guests with a common bath and toilet, a small hall cum dining area, kitchen and a room for the manager. I was told that this had been built for travelling salesmen and the like. But in my three months, there were no other residential guests so I had the bath and toilet to myself.

No residential guests, but plenty of others. Every evening the hotel was filled with the male gender and loud noise. Much like the English pubs, they gathered here for beer, company and conversation. As the evening moved on many were intoxicated, plain drunk.

Given the way the hotel was used, after work I confined myself to my room. It was still spring and very cold. I had a single-bar electric heater in my room. Electricity was provided by the Council via generators which operated for two to three hours between 7 p.m. and 10 p.m. How long I could use my heater depended on how much diesel the Council had that day.

Before light fell, I was in the habit of sitting outside – one could not call it a garden, rather the space between the hotel and the road. This was to catch as much of the sun’s warmth as I could. To do this, I sat in a chair with a book, and while the shadow moved forward with the receding sun, I moved my chair and myself with the decreasing but still available sunlight. This made me a little bit warmer.

Serowe got its water from boreholes located around the village. Water was rationed and supplied to consumers from these sites. The hotel had its rationed supply stored in their own tank. As is to be expected in a supply chain, the water made available to me by the hotel had also to be rationed. Every morning and evening I was given a basin of water.

I requested that I be given less in the morning and more in the evening.

With the basin I was given in the evening, I had my bath. Nalin still asks me how I did it – and my reply is, there was no choice, I just had to. After a day out on dirt roads, walking from house to house in a village one returned hot and dusty. I used a small towel, soaked it, washed the dust off my body, applied soap, and washed that off again with the flannel soaked in clean water. Finally, with the water that was left, I washed my hair. Necessity is indeed the mother of invention.

Meals at the Serowe Hotel

For dinner every night I had a treat – steak. Cattle-rearing is the main occupation of the Motswana. The daily meal of the people was beef with porridge, and so was mine. Only the preparation was different. In the villages they usually cooked it all in one pot – the beef and the grain, like a stew. Sometimes the grain was cooked separately and made into porridge. The grain was either sorghum or millet which they grew in their fields.

The cattle were reared on their family grazing land. The porridge I had for breakfast. For dinner the hotel gave me a choice cut of beef made into a steak, served usually with porridge. Or as an occasional treat, potatoes when they had a supply from South Africa.

From Serowe to Brazzaville

While I was in Serowe I received an urgent message from WHO, Geneva that I should go to Brazzaville to participate as a resource at the Consultation of Directors of Rehabilitation Centres in the African Region. The consultation was to be held from October 8 -12. It was organised by the WHO African Regional Office (AFRO). Gunnel and I were asked to present two papers. One on “A Community-Based Approach to Rehabilitation” and the second on “Manpower Policies in Rehabilitation”. Because Gunnel could not attend, I presented both papers.

Before I came to Brazzaville I had to look up a map to find out where it was. I had actually not heard of it before. And yet the WHO Regional Office for Africa was located here. I found out that what we knew as the “Congo” is two countries. Brazzaville is the capital of what is the Republic of Congo. This had been the French part of the Congo.

The Belgian Congo, or Zaire, is now called the Democratic Republic of Congo. The map showed that while Brazzaville was on the north shore of the Congo River, Kinshasa the capital of the former Belgian Congo was on the south side. From Brazzaville on the north side, I could look across the river and see Kinshasa.

The Democratic Republic of Congo at this time had a military dictator called Mobuto Sese Seko. Economically, the Democratic Republic was doing badly and people were poor. The consultation kept me confined to the hotel with meetings in the evenings and many people to talk with. The little bit I saw of Brazzaville was on my way from and to the airport. What I saw indicated to me that it was a much-neglected city.

It was yet early days for CBR but the discussion and recommendations of this consultation could have a very positive impact for disabled people in Africa. The first output of the consultation was that CBR is the likely solution to meet the needs of disabled people. It called for disabled people, family members, neighbours and friends of disabled people, teachers, community leaders and local authorities to all participate actively in this approach; also, to utilise the principles of primary health care.

Second, it referred to the draft WHO Manual and stated that it will be made available to be adapted by countries for their own use. Third, it referred to the Guide for Policy Makers and Planners which had been recently drafted by Einar in Geneva and recommended its use for CBR planning. Fourth, it referred to the need to develop support and referral systems for CBR and called on rehabilitation institutions to take a leading role in this.

Finally, the consultation stressed the need for multi-purpose or mid-level rehabilitation workers to support CBR. I shall be coming back to the mid-level worker many times later in my journey. For now, I was happy that the need for such a professional was expressed at this important forum; let me say for the first time since WHO introduced CBR.

This consultation led to a workshop in CBR being held in Serowe the following year. I returned to Botswana to facilitate that workshop with Gunnel