Abstract

This paper draws from social narratives as public 'writings' (Weate, 2003), to explain how Eurocentric approaches to rehabilitation based on medicalization and modernization, that is, on normality/abnormality dichotomies, led, paradoxically, to de-welfarization stories and post-modern legacies that were either detrimental to disabled persons in the continent or justified their recourse to new progressive struggles. It proposes to investigate the various postmodern narratives that emerged in Africa as a direct consequence of this medicalization approach supported by professionals and suggests the need for them to take these developments into consideration in order to optimize their rehabilitation output.

The medicalization approach to rehabilitation of 'disabled persons' 1 was a professionalized legacy of the post-industrial revolutionary epoch, based on a pathological set of procedures that defined disability as a 'diseased state', an 'abnormality' that needed to be treated/cured after the diagnosis of symptoms and syndromes of the physical body had been effected. 'Disability' in this sense denoted any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. To be 'handicapped' meant having a disadvantage possessed by a given individual, resulting from an impairment or disability, that limited fulfilment of a role that was normal (depending on age, sex and social and cultural factors) (WHO, 1980: 29). It was presumed that there was an objective condition to which the concept of normality of the body was to be referred, and the role of the rehabilitation professional was to make changes on the body of the disabled person in order to bring it as closely as possible to the condition of normality.

The aim of the medicalization approach was to 'cure' the physical state of the disabled person so that it became 'normal' again and the dis/abled person could re-integrate themselves into what was seen as 'normal' society. The ideological implication of this approach was that disabled persons were biologically and psychologically inferior, were different from members of ordinary society, were not fully 'human' in their nature in comparison to able-bodied persons and did not have the ability to make decisions for themselves. The further interpretation from this was that disability was a personal tragedy of the individual, seen as someone, who could have committed an act that was abnormal. The process of 'curing' an illness involved identifying the cause of the illness clinically and 'controlling' it in order to change the condition of the patient in conventional society. Therefore, the 'normal' society had to invest a lot of resources in sectors like public health care in order to 'cure' disabilities medically, and improve functionality. This task was to be carried out by professionals in the medical field.

However, in the practical contexts of rehabilitation in African societies, social contexts and public spaces, the diagnosis of, for example, a mental illness became chiefly a question of literally interpreting the mind of deranged persons as though it was equitable with conditions of their brains. The practice became one of re-defining certain types of thoughts, feelings, and comportments as if they were signs of the medical disease of derangement itself. Rehabilitation factored the patient's conduct or social behavior into the category of 'abnormality' instead of considering disease from the viewpoint of physical pathology, that is, from a viewpoint of diagnostic information. Consequently, postmodern methods of rehabilitation like sustained sessions of heavy 'battery' of mentally-ill persons for exhibiting certain so-called 'abnormal' and unacceptable behaviours were employed in places like Oku, in the North-West region of Cameroon, in order to coerce them back to a state of 'normalcy'. The mind of the mentally ill person was treated as though it were an object whereas there is a difference between the mind and the biological matter called brain. The matter of the 'brain'/'body' is known through the methods of physics and chemistry, while the mind is identified through interaction, contact and reading. The language employed to analyze the body was literal rather than metaphorical (Szasz, 1961), and this placed the mentally ill African person directly into harms-way.

The presumption underlying modern rehabilitation was that the effects, functions and uses that would be made of the medicalization of impairments and disability would be rationalizable and utilitarian. This turned out to be false because the post-modern uses of medicalization had to do more with social control and public 'hygiene' than with rehabilitation of the disabled person. For example, the medicalization method led to the direct ill-treatment of mentally deranged persons in African countries like Kenya where patients, seen as sub-humans (abnormal) by a Charity Society, were 'locked up and forgotten' for several years resulting in the infliction of bodily injuries and psychological humiliation (see, for example, the programme titled 'World Untold Stories' in website CNN.com/WUS). Although this handling of the body was considered as cruel and uninformed by society, it continued to exist in different forms in several African countries where deranged persons were arrested from public spaces of 'normality' like streets, particularly prior to and during important political and social events. This action was often justified by the claim that activities of mentally ill persons were unhygienic and the public space needed to be cleaned to render it agreeable for 'normal' society. In this way, medicalization led to new forms of social discrimination, control and stigma that really had nothing to do with their brains but more to do with their minds, that is, their moods, attitudes and conducts considered to be 'abnormal'. Yet, it was not their minds that were sick (for which they were being detained and drugged) but their mental faculties that did not need incarceration to be treated or cured. The brain was treated as if it was the same thing as the mind; whereas one could be sick in the brain without necessarily being sick in the mind. Even when these incidents of abusive confinement were reported to the media, and photographed in public, the deprivation of their freedom was seen as a normal requirement whereas there was nothing normal in equating mentally deranged people with imprisoned criminals.

I argue here that this modernist model from which rehabilitation was inspired created these kinds of postmodern conditions of violation of human rights based on the presumption that the 'normal' public was at risk of potentially fatalistic contact with the 'abnormal' population of the mentally deranged population. Consequently, the latter's rights to freedom were waived or withdrawn without subjecting them to due processes of the law on protection of those rights. In addition, with disconnectedness between processes of the brain and the thoughts and sensitivities of the human mind, it was very easy for various organizations to take advantage of this very fluid situation to claim that they had remedies for the problem. For example, in Bamenda city of the North West region of Cameroon, different associations were created to mobilize mentally ill patients to beg for money from the public. In this way, the intention was to take advantage of the medically abnormalized conditions of patients for economic gains rather than to treat or cure them. However, over and beyond economic gains, was the vitally important fact that there was no documented follow-up process of engagement with the associations to see if the technologies of control they had evolved could be developed further and supported for the benefit of the mentally insane persons. Understandably, these associations sought financial support from the public but when the flows were not regular, they had to end their activities that could have been explored for the benefit of the mentally ill persons.

In addition, enough scientific research was not carried out to effectively address this problem of a link between the brain and the mind because, for social, political and/or economic reasons, this sector of disability was judged to be of low priority. Mentally ill Africans could not organize themselves, for example, politically, to pressurize 'normal' society to research into these problems. Consequently, 'normal' society dumped them and their lifestyle into an imagined realm of the 'abnormal' and this categorization was employed in unorthodox ways as an instrument of 'biopower' (to borrow the term from Michel Foucault, 1965).

The issue also shifted from the focus on medicalization to the question of the disabled person as a whole in terms of his psychological and social characteristics. It is a truism that 'biology' simply cannot be considered as providing the only mechanical account for psychological disorders. Psychology is also based on cognitive and social processes. Biology may explain the form that a disease takes; it may even account for the processes, the mechanisms, in short the how, that engendered a disease. But in Africa, (western conceptions of) biology failed to explain the functionality or the why of diseases. Because of this failure, a gap was created that had to be filled up. Disability was then seen as a supernatural effect, the consequence of witchcraft or the punishment endured by a child for the evil deeds of his parents. Prior to the European civilizing mission, in some African societies, disability was defined as a disorder, a curse, which could be addressed only through ritual processes and supernatural intervention. As narrated, for example, by Chinua Achebe (1958) in his Things Fall Apart, in Igboland, the patient was diagnosed, biologically, as a 'twin', as someone suffering from an 'impairment' like elephantiasis or from any other disorder and the treatment consisted in throwing them into a biopolitical space (Foucault's term) called the 'evil forest'. Rehabilitation, in this case, consisted in creating a dichotomized society comprised of 'geographies of exclusion' (to borrow the term from Sibley, 1985) that alienated the 'good'/normal society from the 'bad'/abnormal society. This way of rehabilitating 'disability', resulted in the mortality of the patient because it was intertwined with the politics of social class and was ritualized culturally. Here, clearly, biology accounted only for the how of disability, but had no role to play in explaining the why of the disorder, its complex meanings, cultural purposes and political functions.

After the advent of the modern age, the Eurocentric concept of disability based on 'biology' was expanded to incorporate new areas of development. Disability became a very difficult experience for the African disabled person, who had to deal now not only with a harsh economic environment for his own survival, but also had to come to terms with psychological variables of shame, social variables of (under)class categorization, environmental variables of accessibility, etc. The medicalization of disability in Africa did not lead to the emancipation of African disabled people, but paradoxically led to the degradation of their social conditions. The scarce resources that national governments and societies afforded were used to change the 'body' (through surgical, occupational interventions, fabrication of prosthetics, drugs, cures, tests, genetic screening, diagnosis, medical procedures, new technologies, etc) but the larger social environment of disabled persons was ignored. This policy resulted in the creation of civil rights movements and advocacy groups that castigated official medical and administrative institutions charged with rehabilitation for reducing disabled people to subjects of pity reflecting images of negativity and disempowerment. As a result of the pressure that medicalization exerted on disabled people to conform to pre-set standards of bodily perfection and 'normalcy', the disability issue transformed into a political, social and environmental problem rather than into a strictly medicalized welfare matter.

In African modern societies, the perception of disease created a shift in focus from anxieties with the individual body to fixations on the community and society as a whole. The issue of disability was now seen as a creation not by individuals but by societal, cultural and organizational conditions. Disability was increasingly being perceived more in terms of social barriers, such as inaccessible buildings, impracticable transport networks, stigmatizing social attitudes, demoralizing prejudices and institutionalized discrimination. For African disabled persons, the real concerns were no longer with their individual bodies per se, but with the relationship between their so-called impaired bodies and their social environments. Consequently, the problem increasingly moved away from disability as a biological construct to become a matter of society's attitudes, its cultural assumptions and its material failure to provide sufficient and appropriate services. The impairment of bodies was interpreted not simplistically as events that came by chance, but as effects from a direct result of structural factors created within society.

The emerging view was that society was disabling to disabled persons, not impairments themselves; disability was imposed by social structures on these persons by excluding them and denying their participation in society. For example, in the North West and all the other regions of Cameroon, the dialectical process manifested with the creation of more than fifty associations and organizations aiming to protect disabled persons and defend their rights. With the administrative environments seen as sub-normal; their sub-normality was then blamed for any perceived inadequacies in the bodies of disabled persons. For example, as paradoxical as it may sound, the Ministry of Social Affairs in Yaoundé and its Delegation in the North West region in Bamenda are found in elevated floors of storey buildings inaccessible to wheelchair owners. One of the delegations of sports in the region is found in the ground floor of the same storey building shared by the delegation of social affairs. When staff members were queried to explain why their public structures and services were inaccessible to disabled persons, their cautious answers showed that they had a generally vested interest not to radically question the injustice behind the poor quality of the environment. But given that, as civil servants, they themselves were part of the environment from which they derived their livelihood, there was not much that could be expected from their intervention for the past ten years or so.

As a way of putting pressure on the state to change its venue, the disabled persons in the Bamenda region opted to set up placards at the stair entrance to the delegation so that no one (even the officials) could access their offices and their human rights could be respected at last. But the response from the officials was that this should not be the appropriate step to take because the government had been doing everything possible for the past five years or so to accommodate the delegation in a new building out of the centre of the city! Although this response was consistent with the medicalised approach to disability, which sees the disabled person as physically and intellectually inferior, as unable to take proper decisions for themselves and which confers greater power on the delegation as decision makers, my feeling is that pressure from the disabled persons would mount and diversify with time. My other feeling is that officials of this delegation are willing to help in whatever way they can but it is also exaggerating, at this present time, to expect them to radicalize the system they depend upon in order to bring about revolutionary change. Consequently, the issue presently was the failure of this ideologically structured environment to adjust to the delicate needs and desires of persons with disabilities rather than their individual inabilities to adapt to society's demands. The body was not the factor of culpability here but the product of social inequalities, injustice, poverty and oppression. The guilty factor was no longer the medicalized body but society itself.

The post-modernization narrative took the form of definitional narratives that was greatly contested. New questions were asked in intellectual circles: for example, how could this group of people be named as 'persons with disabilities', 'persons with special needs', 'persons with physical challenge' etc, without reinforcing the same stereotypes that were used to justify their exclusion? New voices argued that this was unfair and was a social conspiracy to 'colonize' disabled persons because to 'name' is to 'control'. The disabled person did not carry out his/her daily activities by reminding themselves each moment of the way that they were disabled; they just lived through the day like any other person. There was no such structuration of names for (normal) people like 'people with malaria', 'people who are physically beautiful', 'people with thin stomachs', 'women with thin lips', etc, so why the obsession with 'people with disabilities'? In Cameroonian public discourse, this problem was solved with the name 'Eboa' which was used as pseudonym in replacement of and for any 'disabled person' and was employed particularly in the specific context of the service sector such as shoe repairing. Cameroonians all over the country usually say: 'please take my shoe to Eboa!'; they do not say 'please, take my shoe to that person with physical disabilities, who is a shoe repairer sitting by the side of the road!' The use of the name 'Eboa' has become so fossilized and normalized in the habitus of national designation and expression that it does not shock anyone anymore to use such a referent but is instead employed with the implication of 'prestige' and admiration because it is employed to mean 'take my shoe to that person, who is very skilful in repairing shoes just as the disabled musician Eboa Lottin was very skilful in composing songs everyone enjoyed up to this day'.

The post-modern narrative went even further beyond medicalization, as has been confirmed elsewhere (Shakespeare, 2006: 34), to urge that there were also impairments caused by 'poverty, malnutrition, war" and so on. In fact, the number of disabled persons increased as a result of poverty induced by the failure of several structural adjustment programmes implemented. In addition, as the aging population of Africa increased, exposed to more factors like technological and social changes, conflicts and terrorism (Coleridge, 1993: Ingstad, 2001), the population of its disabled persons increased as well and, with this, there was the need for creation of more rehabilitation centres with new and elaborate strategies to cater for increasingly sophisticated cases of disability. In fact, anything could generate disability and not simplistically the excessively personalized and medicalized frailties of the individual. The disabled population argued from these examples that what is considered as an impairment is not really something that is 'out there' as medicalization therapists tended to suggest, but that it was a question of social prejudice and judgment. Indeed, what was viewed as impairment in one society did not necessarily have the same relevance in another because expectations and arrangements were different. For example, 'dyslexia' is not a major problem in Africa, yet it is considered as an important 'educational difficulty' in western societies where literacy and the ability to develop Cartesian skills in Arithmetic are essential conditions for economic and social participation.

These examples show that the definition of disability was not a fixed absolute in Africa nor elsewhere; it was capable of taking different forms throughout different social contexts and historical moments. During the pre-colonial era, the disabled person in many African societies was integrated into local communities because the dominant mode of production that was agrarian, based on animal breeding and fishing, was informed by the prevailing ideological concept that the economy should be embedded in society. In this indigenous context, there was no critical difference between able-bodied and disable-bodied persons, although, in some tribes as cited above, such as among the Igbos portrayed in Chinua Achebe's Things Fall Apart, twins and persons with elephantiasis and other disabling impairments were isolated and abandoned into the 'evil forest'. However, with the advent of colonial rule, there was a systematic process of disembeddedness of the economy from society, no doubt a legacy of the effects of the industrial revolution and the implantation of capitalism. From this moment, when capitalism started to gradually encroach into the continent, there was a distinction between labour/non-labour forces. The labour force was assimilated to bodily fitness and the non-labour force to incapacity of bodily function; with both engendering ideas of the deserving/undeserving, with the places of work/home filtering into a work-based and needs- based system of distribution of resources. The needs-based system opened up the way to the professionalization field of rehabilitation with its accompanying attitudes of ostracism, discrimination and resulting oppression of disabled persons as second class citizens.

Particularly, from the 1990s and the decade of 2000, motivated by the feeling that the state (for various reasons like neoliberal policies of capitalism) had abandoned them, African disabled persons began to regard themselves as an oppressed social group. As the problem now was no longer their bodies but their 'disabling world' that had to be confronted 'out there', they responded to this problem of the 'disabling world' by creating different federations, associations, groups, foundations, etc, as a way of organizing their social visibility and pressing for their ideological impact in state policies in effective ways. As a postmodern narrative, the discourse of body shifted into that of human rights. For example, in the organizations that they created, they argued that professional and official structures charged with rehabilitation had no right to dictate to them how they were to live their lives. They realized that their task was to deconstruct the power that these various structures wielded on them. The emphasis was now on choice, on ways of meeting their physical, social, emotional and spiritual needs than on control of their lives.

The response from disabled persons associations, groups, and federations such as the moribund National Federation of Associations of Disabled Persons of Cameroon (FENAHCAM) was to raise awareness of economic barriers, social needs and the negative attitudes they unleashed to a potentially political level. In Cameroon, some of the groups called upon disabled people to vote for particular political parties, while some disabled personalities called for the creation of a Secretariat of State in charge of Disabled Persons' Affairs, the founding of a national board for the social and economic integration of disabled persons and for disabled persons to be represented in the Senate House, Parliament, etc. Others asked that the constitutional texts protecting the rights of disabled persons should be reformed to avoid clauses that gave room to discretionary (optional) applications, arbitrariness of sanctions, definitional problems, etc. This translated into campaigns for the signing and effective application of legislation in such areas as anti-discrimination, access to educational facilities, increased ratio of employment for the disabled, access to public buildings, etc. But there were also moments when these struggles led to internal conflicts among the populations of disabled persons themselves and within and across their many organizations. For example, there were accusations and counter-accusations of corruption, ambition, incompetence, embezzlement, unaccountability, etc, and some disabled persons opted for the extremist suggestion that groups, and associations of disabled persons should be policed to root out what they called recalcitrant ones! This paper argues, however, that all of these sociological developments were simply the manifestations of postmodern narratives that could take any direction, valid or unvalid. What is critically important here and should not be lost sight of is that these narratives were driven by the new agenda of altering the medicalization dynamics within incompatible physical structures, alienated spaces, stereotyped attitudes and geographies of exclusion.

The last decade ended with the impression that the state in Africa was powerless and could not do much for disabled persons. There was an increasing disillusionment among the population of disabled persons drawn from the feeling that the state itself was a victim of powerful global and neoclassical forces: the free market, privatization, deregulation, etc, as theorized by Milton Friedman and that the days of Keynesianism (as advocated by John Maynard Keynes) were being counted. In this era of globalization when what mattered was the free flow of goods and services, ideas, people and technologies, the welfare policies that the state was committed to was undergoing systematic erasure. The state was called upon to disappear and give way to multinational corporations and the competitive market. Consequently, the era witnessed attempts of disabled people to respond by integrating themselves into the competitive market through activities in the local economic and social sectors that promised some tangible benefits. For example, many disabled people were trained to operate in the computer and cyber internet businesses, they became petty traders, service providers selling cigarettes and signing contracts with multinational corporations to distribute cell phone cards. Unfortunately, many disabled persons could not make ends to meet and made recourse to begging in street corners although one must be careful here not to simply condemn the latter as lazy and unprogressive. Begging was the new economic activity into which 'normal' competitive society had pushed them into; it was not necessarily what they opted to do. Other disabled persons tried their skills in specialized forms of football and basketball and organized themselves in championships in order to prove the point that they were not 'abnormal' but were just people like any other ones. In short, the problem of disability could no longer be considered in chiefly individualistic and medical terms (Barnes and Mercer, 2003).

I would like to conclude this paper by stating that the medical approach to rehabilitation has created unacceptable scenarios of illegal confinement, abuse, and drugging. There was a general feeling in public discourses, rallies, various celebrations of the International Day of Disabled Persons, etc, that disability was no longer a problem that persons had, but had become rather a difficulty created for them (Swain, French and Cameron, 2003:23). Today, disability has ceased to mean a personal flaw and is now signified as the product of forms of exclusion caused by different obstacles at the levels of physical, environmental, health, and educational, legal, cultural and social life. This perspective has broadened the experiences of disabled persons from the class into which they were slotted but has also increased their intolerance towards society because medicalization of rehabilitation is now intertwined with political oppression. It is compared to other forms of social oppression such as sexism, racism, class and sexuality (Thomas, 2004). Nevertheless, it is time to address the negative legacies of medicalization based on the 'normality'/'abnormality' dichotomy. Evidently, this typology is based on notions of intellectual and physical 'normality', and that disability and handicap are caused by psychological or physiological 'abnormality' or impairment. But it is clear that, perceptions of 'impairment' and 'normality' are social phenomena that are not easily defined, and are subject to substantive temporal, cultural and situational variation (Ingstad and Whyte, 1995).

Implicit in medicalization is the assertion that the human body is flexible and adaptable while the physical and/or social environments are not. This clearly flies in the face of reality since historically humans have always moulded the environment to suit their needs rather than the other way round (Barnes, 1991). Medicalization suggests that impairment, disability and handicap are static states. Apart from the fact that this is inaccurate, it creates distinctions and barriers between people where there need not be such. Besides reflecting a particularly narrow set of Eurocentric values about what is and what is not biologically socially acceptable, medicalization presents impairment/s as the primary cause of disability and handicap. In this context, therefore, 'rehabilitation is both a philosophy and a practice' designed to eradicate the problem of impairment in order to enable those with 'accredited' impairments 'to function at their highest possible physical, social and psychological levels' (Albrecht, 1992: 23). In other words disabled people should become objects to be cured, treated, trained and changed and made 'normal' according to a particular set of socio-cultural, economistic and technologized values. The limitations of such an intervention have been pointed out by African disabled activists and disabled persons across the world since the 1960s (Hunt, 1966: Sutherland, 1981 (a), (b): Zola, 1982).

References

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Endnotes

  1. I am using the term 'disabled persons', 'disabled people', 'deranged persons,' etc, with precaution for pedagogical and referential reasons than by ideological conviction. I do not believe personally that there is such a thing as 'disabled persons', 'persons with a physical challenge'. I think these are just persons no more nor less than there are 'persons with brown skins', 'persons with round legs', 'persons with small eyes', etc.


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