The Changing Face of Community-Based Rehabilitation—New Features
Trend toward Inclusive Development
In concept, and slowly but surely in practice, “Community Based Rehabilitation” (CBR) has been evolving in empowering and potentially liberating ways since it was launched by the World Health Organization (WHO) 3 decades ago. Indeed, the politics and social philosophy behind CBR have metamorphosed so radically that Chapal Khasnabis, current CBR wizard at WHO, now shuns the term “Community Based Rehabilitation.” Rather he champions “Community Based Inclusive Development.”
This conceptual transformation of CBR was strikingly palpable at the 2nd Continental Congress on CBR held in the city of Oaxaca, Mexico, March 3–5, 2010. The Congress was a major event, sponsored by various UN agencies, government institutions, and non-governmental organizations. Most of the 600+ participants are active in non-government CBR initiatives. They came from 16 countries of the Americas and the Caribbean.
Increased Leadership by Persons with Disabilities
In keeping with the theme of the Congress “Hacia el Desarrollo Inclusivo” (Toward Inclusive Development), a refreshingly large percentage of the participants, as well as speakers, were people with disability. Leaders from a wide range of associations of disabled people took active part. This strong representation of people with disability was a welcome change from the previous CBR Congress—and many others like it—which have typically been dominated by high-level non-disabled hot-shots, with only the showcase inclusion of a few “token crips.”
Greater Focus on Human Rights—of Everyone
Likewise, in the spirit of inclusiveness, at this Congress in Oaxaca there was strong emphasis on basic human ights, and the need to struggle for equal opportunities for everyone, including other marginalized groups. Equity-oriented development of the community as a whole was clearly and appropriately highlighted.
In this context, there was considerable emphasis on the vicious causative cycle between disability and poverty, and therefore attention was given to the need for an economic and development model—from the local to the global level—that empowers the poor and guarantees that all people will have the resources to meet their basic needs. In the world today over one billion people (1 out of every 7) are hungry, and the number is growing. Children are hit especially hard by this fact. Community rehabilitation must enable and mobilize all who are disabled, impoverished, hungry or marginalized. Thus “Inclusive Development” has to grapple with the biggest challenges currently facing humanity and the planet in the 21st Century.
From ‘Training’ to Empowerment
The original theoretical design of CBR, back in the 1980s, was for the most part top down. Governments, rehab professionals, non-governmental organizations (NGOs), community leaders, volunteer “local coordinators” and marginalized families were all expected to work together to “train” disabled people to function better and “integrate” more fully into the community, which in turn would be educated to accept them. (The first CBR manual was titled “Training Disabled People in the Community.”) These were, as far as they went, laudable goals. What was often lacking was the inclusion of the people with disabilities as equals in the planning and decision making processes. From what I heard at this congress, it would appear that this problem has been recognized and is being addressed.
Government and NGOs Working More Closely Together (Sometimes)
One of the outstanding features of the 2nd Continental Congress on CBR was the participation and building of alliances between government and non-governmental programs. Present and participating at the Congress, at least for the first days, were the heads of the DIF (Integral Family Development) program of Mexico at both the national and state levels. (In Mexico, most governmental programs and services concerning disability are coordinated by the DIF, which are headed by the wives of the current elected president or governor.) The DIF directors gave very supportive speeches at the beginning of the Congress. At the close of the Congress, the President’s wife (head of DIF for the nation) announced that Community-Based Rehabilitation would henceforth become an official nationwide program, promoted by DIF working together with NGOs.
Confronting the Institutionalized Abuse of Power
Greater cooperation between government and non-government initiatives is, at least in theory, a big step forward. However, in nations or communities where the government has strong ties to an elite minority committed to policies that widen the gap between rich and poor, problems tend to emerge. In most countries, at least in Latin America, governments have dragged their heels in launching CBR programs. Of the few programs spearheaded by governments, most have petered out. With few exceptions, the most vibrant and successful CBR programs have been initiated by NGOs, religious orders, and (more recently) by organizations of disabled persons themselves.
It remains to be seen how much the CBR goal—based on equitable inclusion of marginalized groups—translates into effective praxis.
The Need for Experienced Welfare Program Chiefs, Rather than First Ladies
In each round of national, state and minicipal elections, new presidents and governors come into power, and their wives become the new heads of DIF at different levels. In this congress these women were quite supportive and were clearly making a strong effort, and with good luck they will continue to. Nevertheless, these directors are not chosen to head these important family services because of their qualifications, interest or abilities. Furthermore, they often dismiss the experienced former staff to employ their personal friends, and replace successfull programs with untried new ones, often with more emphasis on appearances than demonstrable benefits.
A suggestion which was widely discussed in whispers at the Congress was that governments should reassess the tradition of putting “first wives” of top politicians in charge of public-service institutions. Instead, they should enlist the services of experienced persons who have a track record of compassionately working for the rights and empowerment of the disadvantaged. Although many participants at the Congress thought this was a good idea, I was told it would be virtually impossible to change such an entrenched tradition. Equalization of power is more easily dreamed of than acheived.
Toward a Broader, More Flexible Definition of CBR
Another positive trend that became clear in the Congress is an increased flexibility in defining what CBR is. The original designers of the CBR concept—mostly European rehab professionals—instituted a fairly rigid definition of CBR. To qualify, a program had to fit into a specific box, with detailed dos and don’ts. If a program did not conform to the official recipe, it could not be called Community Based Rehabilitation—and was therefore excluded from the club.
The rigid prescription for CBR of course contradicted the underlying vision of diversity and inclusiveness. To those of us with disabilities who worked in community programs, these inflexible recipes for inclusion struck us as counterproductive. If CBR were to evolve into a liberating process, there needed to be a wide diveristy of approaches. No preordained model should be upheld as the right one. Programs needed to be able to innovate and be creative: to experiment and adapt to local needs and possibilities. Some improvisations would work out well and some not. By networking, we could all learn from each other’s mistakes and successes. Through trial and error CBR could improve and evolve. The quest for inclusion would remain an adventure, not a prescription.
FREEDOM OF CHOICE
When CBR was first promoted, it was fairly rigidly defined by professionals. Local communities had little ‘freedom of choice’ to change or adapt the prescribed model. Now things are changing: from top-down to bottom-up. People with disabilities are increasingly becoming leaders, or subjects of the CBR process, rather than meekly remaining recipients, or objects.
The Central Role of Organizations of People with Disability
Disabled activitsts have advocated for open-ended diversity in the implementation of community prgorams for many years. Many were highly critical of CBR. They resisted “rehabilitation” according to other people’s rules. They didn’t want to be “normalized” into an unfair and hierarchical society. Rather, they wanted to change society: to make it more inclusive, more equitable, and more welcoming of diversity. As Joshua Malinga, the South African disabled activist, said, “It’s society that needs to be rehabilitated!”
Professionals On Tap and Not On Top
This groundswell from below—from the disabled community and their advocates—has had a transformative influence on CBR. The new movers and shakers for the process in WHO and other UN organizations—as represented by Chapal Khasnabis of WHO—have become outspoken champions of diversity within CBR, and advocate for the exploration of a wide variety of models. They encourage greater leadership by people with disabilities and their family members, and insist that service providers and professionals be on tap and not on top. Today the promoters of CBR not only use the rhetoric of empowerment, but are beginning to stand to one side and let people organize and innovate on their own terms.
Of course this process of empowerment and inclusion is still far from complete, and it will remain so as long as we live in such a stratified society.
Social Justice From the Bottom Up
What I found most exciting about the CBR Congress is the spirit of change. People on the bottom are no longer willing simply to be trained to fit in. They want to join with other marginalized peoples in the struggle for a fairer, more inclusive, more egalitarian society.
For all its organizational foibles, I found the Oaxaca Congress exhilarating. Who knows?—Perhaps humanity has a small chance of surviving after all!