Speech and Language Treatment in East Africa Speech and language (SL) treatment in East Africa consists of little treatment islands in Nairobi and Mombasa in Kenya, Moshi in Tanzania, and Kampala in Uganda. But demand is immense. Research in Uganda has shown that half the population with disabilities (10% of the total population of 26 million) have ... World Beat
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World Beat  |   February 01, 2006
Speech and Language Treatment in East Africa
Author Notes
  • Angela Jochmann, is a neurolinguist (Rijksuniversiteit in Groningen, Netherlands) and specializes in the treatment of patients with severe neurological disorders (patients in coma, waking coma, or with Locked-In syndrome). She has been working in Uganda since February 2004, providing adult treatment and training as well as coordinating the set-up of the SL course. Contact her at gela_jochmann@yahoo.de.
    Angela Jochmann, is a neurolinguist (Rijksuniversiteit in Groningen, Netherlands) and specializes in the treatment of patients with severe neurological disorders (patients in coma, waking coma, or with Locked-In syndrome). She has been working in Uganda since February 2004, providing adult treatment and training as well as coordinating the set-up of the SL course. Contact her at gela_jochmann@yahoo.de.×
Article Information
Swallowing, Dysphagia & Feeding Disorders / International & Global / Language Disorders / World Beat
World Beat   |   February 01, 2006
Speech and Language Treatment in East Africa
The ASHA Leader, February 2006, Vol. 11, 8-33. doi:10.1044/leader.WB.11022006.8
The ASHA Leader, February 2006, Vol. 11, 8-33. doi:10.1044/leader.WB.11022006.8
Speech and language (SL) treatment in East Africa consists of little treatment islands in Nairobi and Mombasa in Kenya, Moshi in Tanzania, and Kampala in Uganda. But demand is immense.
Research in Uganda has shown that half the population with disabilities (10% of the total population of 26 million) have communication or feeding disorders (see Hartley & Wirtz, 1999). Brain lesions (caused mostly by road traffic accidents and violence), strokes, brain tumors, cancer, AIDS, and psychological trauma cause SL disorders in another estimated 3% of the population. Furthermore, an estimated 2% of the total population have temporary or permanent voice disorders and disfluencies, thus raising the number of people with communication disorders to approximately 2.6 million in Uganda. At present only one speech-language pathologist and one assistant provide service in Uganda. The percentages are undoubtedly similar in Tanzania and Kenya.
Because service is provided in only four cities in East Africa, access is limited to residents of the cities and their surroundings and to wealthier East (and even Central) Africans who can afford travel and accommodation costs. Service in Kenya is private and users have to pay fees in Aga Khan Hospital, Nairobi Hospital, and Mombasa Hospital. In Uganda service is provided in the biggest governmental hospital, Mulago Hospital, and is free of charge. Mulago Hospital treats about 200 children every year and, since 2004, about 100 adults every year with communication and feeding disorders.
Caseload
The workload of SL clinicians in East Africa differs from that of their European colleagues. Treatment frequency is one reason. Most of the clients only come once or twice because they cannot afford the time or the transport to the hospital. SL treatment consists more of counselling and co-training caretakers on treatment than of giving direct treatment.
The pediatric caseload almost exclusively consists of children with moderate and severe communication and feeding disorders. Cerebral malaria, infectious diseases such as German measles and meningitis, and/or maternal malnourishment during pregnancy and malnourishment of infants and children often cause severe multiple disorders. For example, cerebral malaria can lead to cerebral palsy often combined with deafness and/or blindness. German measles is one of the reasons the Ugandan population has a big percentage of people with hearing impairment or deafness. Children with autism spectrum disorders are often sent to SL treatment because there is currently no institution in Uganda for them.
Among the adults a great percentage of communication and feeding disorders results from open and closed brain injuries caused by road traffic accidents, assaults, and the wars in Uganda, Congo, Sudan, and Somalia. Helmet and safety belt laws were recently implemented in order to reduce the amount of traffic victims. The traffic in East Africa is murderous, with speeding the norm and drunk driving frequent.
The dusty air in cities and the habit of teachers, preachers, and Imams to use a very loud and strained voice while speaking often lead to voice disorders. The eating habits and diet of a lot of East Africans cause a high percentage of chronic gastro-esophageal reflux. Untreated, the risk of laryngitis is increased (and not confirmed but assumed by Ugandan ENTs, the risk of laryngeal cancer is increased as well).
A large percentage of East Africans have AIDS, which can inflict meningitis, tuberculosis, and/or dementia, and the consequences can be respiration, speech, language, and feeding disorders.
Disability
Disability is still linked with stigma in East Africa, especially in rural areas. Caretakers often hide children and adults with disabilities from neighbors. “The devil is in that child,” “This is the result of adultery,” and “God punishes you for your sins,” are phrases a desperate mother or caretaker might encounter.
Families with members with disabilities, especially with communication impairments, are often at the rim of the village communities. The burden is on the mother who is often abandoned by her husband after a child becomes disabled or is born with a disability. The child often is classified as a “village idiot.” Fortunately, because of awareness-raising campaigns and the presence of community-based rehabilitation (CBR) workers, this attitude is slowly vanishing. People are becoming more aware of the causes of disability and learning about the existence of specialists who are able to help.
In 2004, speech and language clinicians carried out a country-wide sensitization campaign in Uganda to train medical, paramedical, and education staff on the identification of communication and feeding disorders and on basic intervention methods. More than 300 people in 29 institutions were trained.
Disability not only has social but also often financial consequences. Health care specialists normally live in the bigger towns and cities. Travel to these specialists is expensive and means that the caretaker cannot work during this time. A stay in the hospital frequently means financial ruin on the family as a caretaker has to accompany the person. Hospital stays are expensive as the hospitals do not provide food and bedding. Drugs have to be paid for and caretakers can often not leave the hospital because they have to wash and feed the sick person.
Cultural Considerations and Ethical Dilemmas
Expatriate speech and language clinicians face several challenges and ethical dilemmas in the treatment of people with communication and feeding disorders in East Africa. One challenge concerns the treatment of Muslims with dysphonias and dysarthrophonias. Because treatment for these disorders includes physical contact, female clinicians are faced with the problem of how to check muscle tone and to train breathing and/or relaxation without touching male Muslims. In the case of one Muslim imam with a laryngectomy, treatment had to stop because the Imam refused to take advice from a white non-Muslim woman.
East Africa’s cultural systems, especially in rural areas, are still dominated by men. Some of the East African clinicians encountered situations where the husband/brother/father of a female client refused treatment given by a white woman because “she will put rebellious ideas into my wife’s/sister’s/daughter’s head.” In one case it was the advice given to a dysphonic woman not to carry too heavy loads and talk at the same time in order to avoid straining the neck muscles. Another incident concerned a woman who was advised to do her breathing exercises in a prone position in order to train costo-abdominal breathing. This led to the remark of a man that “these women try to make my daughter idle.”
Speech and language clinicians have to be very sensitive concerning these issues, and finding the balance between obeying cultural taboos and providing effective treatment is often a tricky affair.
Aphasia treatment poses one challenge in terms of word-finding strategies since word usage demands knowledge about the culture and the way concepts are formed in this culture. For example, stereotypical concepts vary from Western ones (and even vary within Western cultures; I once tried to use American photo cards with German patients and was not very successful as a lot of the pictured objects look different in Germany). A stereotypical fruit in the west is the apple (denoted by a short and monomorphematic word); in Uganda it is the pineapple “enanansi,” denoted by a longer, non-monomorphematic word. (You might have thought it was the banana, but Ugandans have at least six different words for our singular concept of the banana to denote the different types of the fruit). And stereotypical animals for Africans are not elephants and lions (these are more the stereotypical animals Westerners associate with the concept of Africa) but rather goats, cows, or cats.
Highly frequent words are often only bi- or trisyllabic, but the clinician has more work to do to find out what words are highly frequent for the individual/ tribe/ culture. Also, synonyms and antonyms are sometimes very different from the Western ones as they are highly culturally dependent. The word pair “fat-overweight” is not synonymous in most Ugandan cultures; the word pair “fat-beautiful” is.
Most of our treatment material is not useful in the East African context and SL clinicians have to be very flexible to adapt or invent appropriate material.
Facial expressions and body language are highly dependent on cultures. Often the same facial expression conveys different meanings in different cultures. In Western cultures, raising the forehead often indicates doubt. In East Africa it means “yes.” Training the frontalis muscles is thus one of the priorities in the treatment of facial paresis or dysathrophonia.
The training of gestures is an important feature in aphasia treatment, but the clinician needs to know the meaning of the gestures. Beating the top of the left fist with the right open hand has an obscene meaning in German. In Luganda (one of Uganda’s languages), it simply means “full” or “filled.”
Establishing and maintaining eye contact is considered very important in Western SL treatment-of disfluencies, for example. But the possibility of establishing eye contact depends on the hierarchical position of the person: Patients in low tribal/ social positions are not allowed to establish eye contact with somebody who is considered superior, in this case the clinician. This feature of social hierarchy is often encountered among children and women from rural areas and the clinician faces the challenge of finding new treatment strategies to account for this cultural taboo.
Linguistic Challenges
Most languages spoken in East Africa are Bantu languages. Swahili (a mixture of Bantu, Arabic, and other languages) acts as the official language in both Kenya and Tanzania. Uganda has more than 40 languages besides English and Swahili, the majority of which belong to the Bantu family.
Bantu languages compose their whole grammar around 8–12 different semantic noun word classes. Syntax is mostly agglomerative, there are no determiners, and affixes are attached to the noun to denote grammatical relations as modus, tempus, and number. Personal pronouns are attached as prefixes to the noun. Tense markers change the whole verb stem morphemes (as irregular or “strong” verbs in Indoeuropean languages do as well).
For example, in Luganda:
  • to work = omukola

  • I work = nkola

  • you work = okola

  • I worked = nnakoze (near past) and nnakola (far past)

Adjectives and verbs almost always carry the same prefix as the noun. Examples:
  • the human = omuntu

  • the humans = abantu

  • the white human = omuntu omweru

  • the white humans = abantu abeeru

  • the white human works = omuntu omweru akola

  • the white humans work = abantu abeera bakola

Morphology of words is different from most Indoeuropean languages as there are almost no monosyllabic words, and monomorphematic words consist of two or more syllables. Thus we cannot apply some of our treatment strategies of cuing words. Cuing a word via the initial sound does not lead to the desired effect. Cuing the word via the first letter is another challenge as many people do not know how to read or write their tribal language or English. Further, many East African languages do not have a single orthography: “Pineapple” can be “enanansi,” “ennanansi,” “enannansy,” and so on. Often, Ugandans write as they hear the word (a phonetic strategy some Europeans tried to implement in their schools with sometimes rather curious results).
English is far from a phonetical orthography and Ugandans’ writing often reflects phonetical translations. “Facial” can become “fashial,” “books” “buks,” and one of my physiotherapy students who assessed a patient with dysphagia wrote, “the woman joked on her food” when the patient aspirated her porridge ("choked").
With patients with aphasia, the assessment and treatment of writing can be a problem, as it may not be clear whether the spelling is idiosyncratic, phonetical, a functional dyslexia, an acquired dyslexia, or lack of formal education.
The sounds /l/ and /r/ are interchangeable in some Bantu languages. “Makerere” and “Makelele” denote the same object. A clinician needs to know if this is a language feature or a phonetical or a practical problem in order to decide whether to treat it or not. The interchange is also sometimes a social class feature. Some Ugandans consider using /l/ for /r/ as a sign of lesser education.
Treating bilingual and multilingual patients can be difficult if the clinician does not know the languages of the patient. For example, the patient may name a picture in a language the clinician does not know and the accompanying caretaker might tell the clinician that the word is right, not wishing to embarrass the patient or the clinician.
Expatriates providing language treatment are heavily dependent on interpreters (normally a family member of the client). Often the clinician has to check and re-check if the interpreter translates advice and tasks correctly and the clinician also has to make sure that tasks are understood correctly in the beginning by the interpreter before being translated.
Other Challenges
Therapy on the wards of Mulago Hospital requires creativity and flexibility as most of the wards lack equipment, food for the patients, and “basic” needs such as painkillers, catheters, and tubes. Many adult patients with brain injuries suffer from aspiration pneumonia because the nasal tube does not fit, caretakers do not know how to manage a nasal tube (they often feed too fast, too much, and with the patient lying in a horizontal position because beds with movable backrests are rare), nasal tubes stay for weeks without being replaced, and/or two or more patients have to use the same suction machine.
SL intervention consists very often of training the caretakers more than once on nasal tube management. PEGs (percutaneous endoscopic gastrostomies) are rarely used, because they are expensive and carry a stigma in Uganda because they are associated with AIDS and death. Thanks to the dedication of the doctors, nurses, and caretakers, many patients recover from the pneumonias, pressure sores, and other secondary infections.
Tongue tie (ankyloglossia) is one issue surrounded by myth. Often, a mother is told by well-meaning neighbors to let the child’s tongue be cut if the child fails to speak. Frequently, this surgery is performed by traditional healers and the consequences are often infections and badly scarred tissue. Referrals to SL clinicians are rare and if children are referred at all, it is after the surgery. Clinical experience has shown that a lot of these “tongue-tied” children have hearing loss, deafness, or cerebral palsy.
Selective mutism is a disorder very often found in victims of the civil war in Northern Uganda. Former child soldiers and abducted people are too traumatized to be able to express themselves in spoken language.
Although this is a disorder typically treated by psychologists and social workers, both of these professions are rare in Uganda and SL clinicians have to face this disability. Official numbers estimate 12% of the Ugandan population to have a mental disorder but aid workers consider this number too small.
For most of the SL clinicians, workshops and further training in treatment are difficult to access because those take place in Europe and costs are too high for us to participate. SL clinicians have to rely on journals (that are often too expensive as well), Internet resources, and books.
Despite or even because of all these challenges, SL treatment is a highly rewarding task in East Africa. Seeing how little changes have a big effect is very gratifying. Many East Africans also possess a wonderful sense of humor and treatment is often a time with a lot of laughter.
Finally, 2006 will provide us with four new SL clinicians in Uganda and Kenya. Kampala now has a new pediatric specialist, a volunteer with Voluntary Service Overseas (VSO), and Nairobi has received three clinicians: one VSO volunteer and two freelancers. The future is bright.
Contact Us

Clinicians and other people interested in our project, general issues, or a job as a VSO SL clinician are very welcome to contact us at: Angela Jochmann, VSO Uganda, PO Box 2831, Kampala, Uganda. Telephone 256-78-325050.

Books for the Speech and Language Course

Books are a rare and valued treasure in Uganda. Often it is the availability of books that decides the chances of a proper education.

We need your help to set up a resource library for our students who will attend the first speech and language course in Uganda.

Any books covering issues in speech and language treatment are very welcome. Specific areas we need books for are:

  • linguistics (all areas)

  • psychological and social counseling

  • medical sociology

  • neurology, neuroanatomy, neuropsychology

  • community-based rehabilitation

  • physiological disabilities

  • multiple learning disabilities

Donated books would be greatly appreciated. Books can be sent directly to Angela Jochmann at VSO Uganda, PO Box 2831, Kampala, Uganda.

East Africa’s First Speech and Language Course

Since 1986, Volunteer Service Overseas (VSO) has sent speech and language (SL) clinicians to the ENT department in Mulago Hospital in Kampala, Uganda. As this has not proved sustainable because of language problems (Uganda has over 40 local languages) and cultural issues, VSO Uganda and ENT decided in 2002 to set up the first East African Speech and Language Therapy Course together with Makerere University in Kampala. The training of Ugandans and other East Africans as SL clinicians will be much more sustainable and efficient as the trainees know the languages and the culture(s) of the clients and can counsel and treat accordingly.

Writing the curriculum and the modules, dealing with bureaucracy and fundraising, as well as running the pediatric and adult clinics are just some of the challenges we have had to face. With the help of Viataal (a Dutch organization) and Standard Chartered Bank Uganda, we are starting the course this month, in February 2006.

Twenty students each year will be trained in a Higher Diploma course. The two-year course will teach students the basics of anatomy, psychology, sociology, counseling, community-based rehabilitation, linguistics, general assessment, treatment methods, and several communication and feeding disorders. Modules include hearing impairment, language delay and disorders, neurological disorders, physical disabilities, learning disabilities, cleft-lip palate, tongue tie, disfluencies, and selective mutism.

References
Hartley, S., & Wirtz, S. (1999). Service priorities for children with limited communication ability based on disability rather than impairment analysis. Postgraduate Doctor Africa, 21 (4), 89ߝ92.
Hartley, S., & Wirtz, S. (1999). Service priorities for children with limited communication ability based on disability rather than impairment analysis. Postgraduate Doctor Africa, 21 (4), 89ߝ92.×
Robinson, H., Afako, R., Wickenden, M., & Hartley, S. (2002). Preliminary planning training speech and language therapists in Uganda. Folia Phoniatrica et Logopaedica, 55/6, 322ߝ328.
Robinson, H., Afako, R., Wickenden, M., & Hartley, S. (2002). Preliminary planning training speech and language therapists in Uganda. Folia Phoniatrica et Logopaedica, 55/6, 322ߝ328.×
Robinson, H., & Tumweheire, G. (2001). The provision of a centralized speech and language therapy service in Uganda: A 3 year case note study (1999–2001). Unpublished report ENT department, Mulago Hospital, Kampala, Uganda (available from first author and from SLT Mulago, sltuganda@yahoo.co.uk).
Robinson, H., & Tumweheire, G. (2001). The provision of a centralized speech and language therapy service in Uganda: A 3 year case note study (1999–2001). Unpublished report ENT department, Mulago Hospital, Kampala, Uganda (available from first author and from SLT Mulago, sltuganda@yahoo.co.uk).×
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FROM THIS ISSUE
February 2006
Volume 11, Issue 2