Rehabilitation: Educational and International

MR. MACDONALD:

There is surely no more distressing sight than a handicapped child, nor can there be an object of greater hope. In our adult perception, we tend to dwell on the child's limitations and shortcomings, while he, himself, wonders what opportunities await and what dreams may be fulfilled. Yet, hopes and dreams will not suffice without the aid of those possessed of that rare combination of faith and scientific inventiveness. Such people are few in number, but great in importance, and we are privileged to have one of them with us today in the person of Dr. Gustave Gingras.

Among his colleagues in the international community of rehabilitation medicine, Dr. Gingras is a man of immense stature. Among hundreds of humble people throughout the world, he is a symbol of hope. In our country, he is a model of the very best in bilingual accomplishment. Monsieur, nous vous acceuillons au Club de l'Empire et a cette ville. Au meme temps, nous vous remercions de l'honneur que vous nous conferez par l'acte de votre presence parmi nous aujourd'hui.

In terms of basic attitude to Canada, there are two breeds of Canadians: those who are defensive and selfcritical and those who are proud and expansive. There can be no doubt where Dr. Gustave Gingras stands. Listen to the words with which he accepted, last year, the Albert Larker Award at the 11th World Congress of the International Society for Rehabilitation of the Disabled.

"I owe this great honour to my country -Canada. I'll never be thankful enough for what it has done in helping me to carry out my work for the handicapped."

How fitting that he was the first Canadian to receive this award which is one of the most coveted in the field of medicine.

Although his debt to Canada is so freely acknowledged, his repayment has been distributed throughout the world. His citation read, in part:

"Under his leadership, the Rehabilitation Institute of Montreal has provided training opportunities for students from more than twenty countries who have returned to their own lands to apply the precepts of rehabilitation and the inspiration instilled by Dr. Gingras. His international vision and energetic efforts have paved the way for improved services for the handicapped in many parts of the world."

Dr. Gingras has been Executive Director of the Rehabilitation Institute of Montreal since its founding in 1949. He is also Professor of Physical Medicine and Rehabilitation in the Faculty of Medicine, University of Montreal, President of the Quebec College of Physicians and Surgeons, the first Canadian to serve as President of the International Federation of Physical Medicine, a Fellow of several medical societies and a member of numerous medical and scientific associations throughout the world. Nor could I begin to describe his honours, awards, and distinctions.

Perhaps his dramatic performance on the world medical stage is a throwback to an earlier ambition, for I am told that he once dreamed of becoming an actor. Had he not chosen the University of Montreal Medical School instead, I have no doubt that "Anne of a Thousand Days" might well have two Montreal stars--Genevieve Bujold with Gustave Gingras in the place of Richard Burton.

Dr. Gingras began his work with the casualties of World War Two and has continued to serve the victims of senseless killing and pharmaceutical fallout because, in recent times, his most noted contributions have been in Vietnam and with thalidomide children. In both instances, his refusal to be subdued by bureaucracy and his sheer determination have transformed the future for countless children.

In a forthright and intriguing interview in Maclean's, in March 1969, he was reported to have remarked with a tinge of nostalgia: "I used to be a pretty fair physician, but now I'm just a con man." He referred, of course, to his efforts at persuading service clubs, or governments, or both, to provide the means of carrying on his work. I would say that "con" really is an abbreviation for the confidence he has instilled in the disabled, the constancy of his efforts on their behalf, and his contrariness in the face of awesome odds.

Dr. Gingras, like many poets, loves to spend long hours watching the sea, the sea that has hidden depths, unpredictable currents, exciting changes of face and relentless force. It tells us much about the human spirit and so, I believe, does Dr. Gustave Gingras whom I am proud to introduce to you now.

DR. GINGRAS:

I am grateful to the President and Officers of The Empire Club of Canada for giving me the opportunity to address this prestigious group. It is not without humility that I do so after having noted the names of the speakers who have preceded me.

In September 1969, during the Eleventh World Congress, held in Dublin, the International Society for Rehabilitation of the Disabled proclaimed the years 1970 to 1980 "The Decade of Rehabilitation". The projects and major objectives outlined are among the finest and most constructive initiatives ever undertaken by this world federation of voluntary organizations in 61 member countries. As Canadians, it would appear to be our duty to assist in any way possible to assure the practical and productive realization of these important objectives.

In our affluent society, and this applies to the European and North American concept, the various medical and surgical specialties have had a tendency to work independently in the field of rehabilitation. Postgraduate training has often been water-tight and there has been little true scientific or other exchange between the various professional and lay organizations. Fortunately, in recent years, thanks to organizations such as the International Society for Rehabilitation of the Disabled, UNICEF, The League of Red Cross Societies, Save the Children Fund and many other national and international lay and governmental agencies, it has been possible to set up rehabilitation centres and hospital rehabilitation facilities and, to a certain extent, to stack up knowledge and obtain a certain degree of symbiosis. I would be remiss if I did not mention the wonderful work of the Canadian Red Cross Society in the field of rehabilitation in Canada and abroad. The Society gave me the unique opportunity to serve in the past in Morocco during the paralysis outbreak in 1959-60, and I will be eternally grateful for the major experience and opportunity given to me.

It has been often suggested but rarely realized that all facets of a given disability be taught jointly to students in the medical and allied rehabilitation professions. Indeed, it would be more profitable to all rehabilitation students if, for instance, clinical demonstrations were given jointly on spinal cord injuries including the neurological, neurosurgical, orthopaedic, physiatric and plastic surgical aspects. Physical and occupational therapy, prosthetics and vocational aspects could also be included and thus provide all students with a package deal that is both useful and practical. Concurrently, it would strengthen indeed the teamwork concept.

It has been difficult to convince some of our psychiatric colleagues to specialize in the interesting and complex problems of psychiatry as applied to physical disability. Their greater participation in programmes would undoubtedly open new avenues and help solve the ever-increasing psycho-social problems associated with disability.

In order to attain a common goal, the Committee on Guidelines for the Future in Medicine of the International Society for Rehabilitation of the Disabled recommended the following in the field of education:

a) That an attempt be made in all countries to standardize the postgraduate studies in the Specialty of Rehabilitation Medicine.
b) That the training of rehabilitation personnel be intensified at all levels and in all countries.
c) That the undergraduate lectures and clinical demonstrations given in Faculties of Medicine include the participation of the allied rehabilitation professions.
d) That common training, when applicable, be dispensed to students in both the medical and allied professions.
e) That the general practitioner and the pediatrician receive special instructions in the field of rehabilitation.
f) That more psychiatrists devote more of their time to the psychiatric aspects of disability.

Tremendous gains have been made in developing countries in recent years. It is true that the fight for full recognition of the disabled person is not fully won, that architectural barriers are still a major problem, and that research in all fields of rehabilitation is but in its infancy. Nevertheless, thanks to understanding governments, lay agencies and farseeing individuals, arms have been forged and a policy has been established. The major problem is not within the developed countries, however, it is in the Third World.

Cardinal Paul-Emile Leger, who left his prestigious station as Archbishop of Montreal to become a simple missionary priest in The Cameroon, recently said:

"The discovery of the Third World is a recent one. It is one of that complex set of realities which has gradually been brought home to us as a result of the upheavals during the period following the Second World War. For the last twenty-five years, economists, sociologists, psychologists and geographers have tried to get at the heart of a matter which has become the number one problem of our time."

In one of its most forceful presentations yet, the International Review of the International Society for Rehabilitation of the Disabled cites that 500 million or 17% of the world's people live in areas where rehabilitation services are adequate; that 600 million or 18% live where services are developing but still inadequate. In bold capital letters it brings home the almost incredible statement that: "Two billion or 65% of the globe's population live in areas where little or no rehabilitation services are available."

As one who has had the opportunity to observe and study rehabilitation facilities on five continents, I can vouch for the veracity of this statement. The International Society should be commended for bringing this statement to the attention of the world, particularly to that of the affluent societies.

It has been shown time and time again that the main factor involved in organizing rehabilitation facilities in developing countries does not reside in grandiose buildings and sophisticated equipment. Modest facilities and not infrequently locally manufactured equipment are more than sufficient. What is crucially needed and needed now are people--devoted and competent doctors, nurses, therapists, prosthetists and orthotists--supported at home by understanding governments and unselfish public-minded organizations and individuals.

Bringing rehabilitation personnel from developing countries to developed areas for full training has been tried often; in many instances the experiment has failed. Indeed, it must be realized that many of the principles taught in our countries cannot always be applied easily in developing regions owing to lack of facilities, equipment, funds and government co-operation. How many foreign students, after three and four years' training in the United States, Britain, Canada or elsewhere have returned home only to face one lack or frustration after the other until they long to immigrate into the host country? Furthermore, in several instances, the diseases and disabilities present and requiring rehabilitation procedures in developing nations have never existed, or have been almost eradicated, in the developed areas. This statement is particularly true for leprosy, poliomyelitis and tuberculosis. It would appear to many of those who have had experience in this field, and certainly mainly to those in authority in developing regions, that the method of choice the one that produces the best results--consists of seconding men and women who will provide service and education and who, after a job well done, will return home leaving a core of well prepared and well trained nationals to continue the work started.

Another solution advocated, to economize on personnel from developing countries, is to provide regional training. By this method, candidates can be trained in areas similar or almost similar to their own where the types of diseases studied and treated, climate and facilities correspond to that found in their own regions. Going abroad for short courses and exposure to modern rehabilitation methods is of course highly recommended for mature individuals who have already acquired their basic education and training at home.

It is true that in developed countries the professional groups have resisted the training of aides in their respective professions. In developing countries, however, two levels of training are absolutely essential owing to the scarcity of candidates with sufficient educational background for direct admission to courses in the various allied rehabilitation professions. There is no doubt that unless this second level is provided, fully trained personnel will not be available until the overall educational level of a whole given country has risen to one comparable to that of the developed countries. Such an ideal result might not be reached for two generations to come.

The recommendations of the Committee on Guidelines of the International Society for Rehabilitation of the Disabled are short and specific on this point:

a) That every effort be made to train personnel in their country of origin.
b) That regional training be encouraged.
c) That two levels of training for the allied rehabilitation professions be considered, keeping in mind, however, that the quality of the courses be subject to constant review.

Until now very little research has been pursued in rehabilitation medicine because it has been essential to face emergency problems such as treatments, staff training and the creation of facilities. In many areas of the world it was necessary to start from the very beginning and, not infrequently, the rehabilitation teams had to face tremendous backlogs of unattended cases. Of course, it is understood that research in depth is not possible in every country nor in every rehabilitation centre owing to staff, facilities and financial involvement. Nevertheless, it must be strongly emphasized that research should not be confined only to the so-called advanced and well developed areas. Very useful and constructive research and investigation, particularly in the demographic and geographic distribution of disability can be conducted in the developing countries with help from national, regional or international agencies.

Research may be oriented in the following fields:

1) Highly scientific and sophisticated research investigations conducted in well established faculties of medicine, in hospital departments of physical medicine and rehabilitation and in centres associated with universities to deal with muscle physiology, diagnostic procedures and external power sources for prosthetic and orthotic appliances.
2) Specific research on the rehabilitation of certain given pathological aspects little known or "forgotten" in developed countries but prevalent in developing areas, for instance in the field of poliomyelitis, leprosy and tuberculosis.
3) The psycho-social and psychiatric impact of disability on the individual, the family and society at large.
Once more, I wish to quote from the recommendations of the Committee on Guidelines of the International Society for Rehabilitation of the Disabled:
a) That more funds be made available for research in the area of rehabilitation medicine and para-medicine in both developed and developing countries.
b) That surgical techniques, particularly in the field of neurosurgery and orthopaedics be reviewed and improved through research to alleviate deformities.
c) That it would be highly desirable to give attention to research in prenatal life and its ecology.
d) That research be intensified in the field of prevention of accidents and diseases, including blindness and deafness.

The method of delivering adequate services, both at home and abroad, is one of the major problems and, in spite of constant effort at all levels, rehabilitation personnel will undoubtedly continue to be at a premium for many years. It would seem that specially adapted "time and motion studies" should be instituted to investigate the feasibility of economizing on the time of the rehabilitation personnel. The admission requirements in the field of allied rehabilitation professions have increased; the duration of courses have been lengthened and diplomas have been progressively replaced by university degrees in many areas. Consequently, as allied rehabilitation personnel is and will be capable of shouldering greater responsibilities, there is no doubt in my mind that the physician should be able to delegate more to them. Group therapy in Physical, Occupational and Speech Therapy and in Medical Social Service not only saves precious time and effort, but also promotes socialization and healthy competition.

Because of the tremendous recent advances and importance in the rehabilitation field, I have chosen to study separately the problems of orthotics and prosthetics.

A great deal has been done in the field since World War II, and even more since the thalidomide tragedy. In developed countries, new methods of fitting and training have evolved with the utilization of new materials. In many instances plastics have replaced wood and metals, and lighter materials have supplanted the heavier components of braces. It is appropriate to mention here that many of the improvements and miniaturization of components are by-products of space technology and that the disabled should be most grateful for the benefits accrued to them through these wonderful developments. It can be stated that because of the excellence of orthopaedic procedures, the advent of physical medicine and rehabilitation methods and because of the drastic decrease of poliomyelitis, the number of braces prescribed in developed countries has diminished tremendously. On the other hand, their need is increasing daily in developing areas. Greater efforts must be made towards the standardization of parts used in the field of orthotics. Such parts can easily be made in countries where manufacturing facilities are available. Here again, the possibility of establishing regional orthotic workshops may be considered with great advantage.

One of the difficulties in the fitting and use of artificial limbs in developing countries is to convince physicians, prosthetists and allied rehabilitation personnel that the same degree of excellence found in their own countries of origin cannot be attained overnight. In certain areas one must be satisfied with the adequate use of pylons; in others, it may be preferable to train the unilateral upper extremity amputee to maximum use of the remaining limb rather than to provide a complicated prosthesis which may require maintenance by specialists who may not be available.

Technical aid to developing countries must be backed and sustained firmly by the affluent nations. "The rich nations are getting richer and the poor nations are getting poorer" stated Lester B. Pearson, the former Prime Minister of Canada, who some months ago headed a World Bank Commission on International Development. "Foreign aid," added the Nobel Peace Prize Winner, "must be improved and strengthened and one way of doing this is by adhering to the minimum foreign aid standard set for the rich nations by the United Nations. If we falter in doing this then we will face the greatest catastrophe in history--the alienation of the underdeveloped nations."

Mr. Pearson addressed himself to government and government agencies but I am sure that he cannot and would not exclude the support of national and international benevolent organizations and of every citizen of the affluent nations.

Mr. Chairman and Gentlemen, most of us can provide financial help to developing countries, and a larger number of our professional fellow-citizens can give of their time and talent to teach and serve in less favoured territories of the world. This, however, is not enough. We and those who are sent must develop and acquire good will, tolerance and understanding. On my last trip to Viet Nam I again visited the Canadian Rehabilitation Centre in Qui Nhon, which is staffed by Canadians recruited from coast to coast, the majority of whom speak the two official languages of Canada. While appreciating the important assistance rendered by Canada, one of the Vietnamese Cabinet Ministers said to me: "You render to us a great service for which we are and will be eternally grateful, but when the working day is over your personnel return to their quarters until the next day . . . you cannot compete with the missionaries, regardless of their faith. The missionaries live with us, they toil with us, they learn our language, they eat with us . . . sometimes they even die with us!"

Mr. Chairman and Gentlemen: those whom we send abroad must be missionaries in their own right!

May I conclude by quoting from the Book of Enoch:
"If you have much, give much; if you have little, be
not afraid to give according to that little; for you lay up
a good treasure for yourself against the day of need."

Dr. Gingras was thanked on behalf of The Empire Club by Dr. H. V. Cranfield.