Disability and rehabilitation in Zimbabwe: lessons and implications for rehabilitation practice in the U.S. (Disability and Rehabilitation in Zimbabwe).

Conceptions of disability and the associated rehabilitation practices vary widely across societies, and are influenced by the unique sociopolitical and cultural histories of those societies. For example, differences in perspectives on disability and rehabilitation between nations or communities have been linked to differences in (a) cultural beliefs about disabilities; (b) availability and accessibility of scientific knowledge on disabilities and rehabilitation to the general public; (c) the social and economic goals that people in different nations or communities seek to achieve; (d) level of industrialization (or development) of nations and the material resources they have for supporting disability-related programs; (e) ideological commitment to enhancing the quality of life of all citizens; and (f) respect for individual human rights (Brown, 1991; Jenkins, 1998; Talle, 1995). Developed countries are characterized by a belief in natural-scientific explanations of disability, higher levels of formal education among their citizens, individualistic-egalitarian socioeconomic structures, higher levels of industrialization, more organized and better disability-related service resources. In contrast, developing countries tend to have a higher belief in metaphysical-spiritual rather than natural-scientific views of disability, collectivistic-hierarchical socioeconomic structures, lower levels of formal education, lower levels of industrialization, and less organized and less formal rehabilitation service resources (Brown, 1991).

These differences in socio-cultural contexts are important for a cross-cultural understanding of disability and rehabilitation. For instance, developed countries with their more complex socio-technical systems may present more challenges in activities of daily living (e.g., commuting, time management) than do developing countries which tend to have simpler socio-technical systems. A personal characteristic that is not disabling in less complex societies can be a disability in more complex, industrialized societies (Brown, 1991). For example, mild mental retardation is less disabling to community participation among subsistence agricultural farmers in rural sub-Saharan Africa than it would be in the industrialized US (Serpell, Mariga & Harvey, 1993). This is because the activities necessary for a subsistence agricultural economy are less intellectually demanding as compared to those necessary for participation in an industrialized society. On the other hand, persons with more severe disabilities in developing countries may experience more personal restrictions due to the unavailability of appropriate or enabling disability-related accommodations (e.g., assistive devices, disability laws) (Mpofu, 2001). Quite clearly, there are differences in the nature and quality of rehabilitation services between the industrialized and the industrializing countries. At the same time, there are also significant differences in perspectives on and practices in rehabilitation within the industrialized and industrializing countries (Jenkins, 1998; Serpell, 1983).

This article presents an overview of disability and rehabilitation in Zimbabwe. In particular, consideration is given to definitions of disability and rehabilitation from a Zimbabwean perspective, historical foundations of rehabilitation in Zimbabwe, and rehabilitation service structures in the country. Finally, some lessons that may be drawn from the Zimbabwean experience for the practice of rehabilitation in the United States are explored. Because of the international perspective, differences in terminology may exist, thus, common terms are used and when this is not possible, the terms are defined for clarity.

Geographical Location, Demography and Responsiveness to Disability

Zimbabwe is one of eight countries in Southern Africa together with Angola, Botswana, Malawi, Mozambique, Namibia, South Africa, and Zambia. It has a total area of 150,873 square miles (390,759 km2) and a population of about 11 million people (Government of Zimbabwe Central Statistical Office, 1994). About 95% of the population are Blacks and five percent other ethnic groups. Eighty percent of the population are Shonas (a cultural-linguistic group), 15% are Ndebeles, and 5% Asians, Whites and others. Eighty percent of the population lives in rural areas and 20% in the cities. Therefore, the country's economic base is largely agricultural, although manufacturing, mining and tourism are also significant sectors of the economy.

The Government of Zimbabwean Inter-Censual Demographic Survey (1997) established a total of 218,421 people with disabilities in the country (56% males; 44% females). This prevalence is equal to two percent of the national population. Seventy-five percent of people with disabilities lived in rural areas and 25% in urban areas.

Zimbabwe has been referred to as "one of the most disability-accessible countries in Africa" (Devlieger, 1998, p. 26) with greater availability of disability-friendly public transportation policies, disability legislation, and the vocational training and employment opportunities of persons with disabilities as compared to neighboring countries. For example, people with disabilities have free public transportation, and are eligible for a government disability allowance. Schools enrolling students with mental and sensory disabilities are paid a higher grant for each child with a disability that they enroll. If the number of students with disabilities attending an ordinary school reaches seven for students with visual impairment or hearing impairment or ten for students with mental retardation, the government deploys a special needs teacher at that school to assist with the teaching. Zimbabwe is the only country in sub-Saharan Africa with a Schools Psychological Services and Special Needs Department whose responsibility it is to identify, assess, and place students with disabilities in schools.

Zimbabwe has nine large, state rehabilitation centers covering developmental and acquired disabilities (five), and psychiatric disabilities (four). In addition, each of the country's 10 provincial hospitals has a rehabilitation unit (Mpofu, 2001). The national rehabilitation centers are variously staffed by professionals with diploma, bachelor or master qualifications in medicine, social work, psychology, speech pathology, physiotherapy, occupational therapy, nursing, and a number of commercial/industrial subjects.

The country stands alone in sub-Saharan Africa for having disability legislation. The Disabled Persons Act of Zimbabwe was enacted in 1994 for the purpose of enhancing the educational, social and occupational interests of Zimbabweans with disabilities. The Disabled Persons Act of Zimbabwe, among other things, mandates a National Disability Board whose purpose it is to help with advising on issues relating to people with disabilities. Specifically, the National Disability Board has the following responsibilities to (a) formulate and develop measures and policies on the rights and welfare of people with disabilities; (b) maintain a register of people with disabilities and disability-related organizations; and (c) advise government and non-governmental organizations on the welfare and rehabilitation of people with disabilities (Government of Zimbabwe, 1996). The National Disability Board comprises 15 members as follows: three representatives government ministries (i.e., Health, Education, and Social Welfare), a representative of employer organizations, a representative from the trade unions, and 10 members representing disability organizations of people with disabilities. The chair of the National Disability Board must be a person with a disability.

Zimbabwe's prominent regional standing in disability management and rehabilitation is also attested to by the fact that the country has a total of 56 organizations for and of people with disabilities (Chimedza, 2000). The organizations vary from disability specific organizations e.g., Epilepsy Support Foundation of Zimbabwe (ESFZ); Quadriplegics and Paraplegics Association (QPA), organizations for people with disabilities in general (e.g., National Council for the Disabled Persons of Zimbabwe (NCDPZ); National Foundation for the Disabled (NAFOD); and support organizations e.g., Zimbabwe Parents of Handicapped Children Association (ZPHCA). Some of the disability-related organizations have coordinating functions. Examples are the National Association of Societies for the Care of the Handicapped (NASCOH), and the Southern African Association for People with Disabilities (SAFOD). NASCOH is an umbrella organization for 53 organizations for and of people with disabilities. SAFOD is the coordinating body for organizations of and for people with disabilities in Southern Africa. Zimbabwe is also home to the Africa Rehabilitation Institute (ARI). The African Rehabilitation Institute is a multinational organization whose primary goal is to promote the initiation and development of rehabilitation services in sub-Saharan Africa.

Defining Disability and Rehabilitation in Zimbabwe

Developing countries like Zimbabwe have parallel definitions of disability and rehabilitation; indigenous-traditional and modern. This is because Zimbabwe is a society in transition from a pre-literate, rural-agricultural towards a modern, industrialized society. Historically, societies in transition tend to have both modern-scientific and traditional-metaphysical views regarding occurrence of phenomenon (Ackerknecht, 1982).

Zimbabwean Indigenous-traditional Conceptions of Disability

Zimbabwean traditional or indigenous conceptions of disability tend to regard disability as a limitation in social role function resulting from physical, sensory or emotional abnormalities and is of spiritual causation. For example, the notion that people with disabilities have limitations in social role functioning is suggested by use of the word "lema" or "rema" (i.e., become heavy, fail, or experience difficulty) by the major indigenous Zimbabwean languages (i.e., Shona; Ndebele) to refer to a person with a disability. In other words, having a disability is considered to make an individual incapable of many roles.

The Zimbabwean Shona and Ndebele languages are spoken by 98% of the population. They are part of a larger group of Bantu languages that are spoken throughout sub-Saharan Africa. In the family of sub-Saharan Bantu languages, the word `lema' or `rema' is prefixed by the object or animal-referent `ki', `chi' or `isi' (for `it') as in `kilema' (e.g., in Kiluba, Kisanga, Songye languages: Angola, Congo, Zambia), `chirema' (Shona language: Mozambique, Zimbabwe) or `isilima' (Ndebele/Nguni: Malawi, South Africa, Tanzania, Zimbabwe) or human-referent `mu' as in `mulema' (e.g., in Kiluba, Kisanga, Songye languages) (disability) (Burch, 1989; Devlieger, 1998). Therefore, indigenous Zimbabwean (and sub-Saharan African) conceptions of disability consider a person with a physical disability as at the borderline between a human being and an animal (Devlieger, 1998).

There are rural-urban differences in the salience of role marginalization as a characteristic defining disability status (Mpofu, 1999). For instance, people with disabilities in rural areas are seen by significant others (who are often fellow villagers and or relations) in more socially valued social roles (e.g., livestock-tending, home-keeping, child-care) than those in urban areas. This positive visibility mitigates the perceived lack of social role function of individuals with disabilities in rural as compared to urban areas. People with disabilities in urban settings are not readily seen performing similar roles by others who may come from different parts of the city, or are in homes which are often literally fenced in brick walls. Home fencing with bricks or wire is a common practice in Zimbabwean and other African cities. The practice is thought to add to the security of property as well as enhance privacy. Thus, people with disabilities in urban areas may be defined more by their role marginalization than peers in rural areas.

In the Zimbabwean context, role marginalization is salient to defining older people and females with disabilities than younger people and males with disabilities. For example, older people with disabilities are held to higher social role performance expectations than the younger people with disabilities. They are also likely to be perceived as failing in those roles. Indigenous Zimbabwean cultures have higher role performance expectations for males than for females (Mpofu, 1983), and this bias could add to the perception that ascription of disability status is more appropriate to females with disabilities than their male counterparts.

Disabilities are presumed to be of spiritual origin. The disability causing spirit is often regarded as a malevolent spirit (the winds) (or mamhepo: Shona language), an avenging spirit (ngozi: Shona/Ndebele), or a benevolent spirit (mudzimu: Shona language; Indlozi: Ndebele). A malevolent spirit is one that is cast on a person by his or her enemies and may cause a disability at anytime in a person's life. For example, it is believed that a pregnant woman who has the winds cast upon her may give birth to a child with a disability. Also, a child may acquire a disability after birth if a witch cast some winds on it. A malevolent spirit may be regarded as behind any disability causing injuries that are sustained at work. Malevolent spirits could be in the form of "thokoloshis" (Ndebele) or "zvikwambo" (Shona) (i.e., goblins) who impregnate women in their sleep, leading to the birth of a child with a disability.

Traditionalist Zimbabweans believe in an avenging spirit. An avenging spirit is that of a person whose death is known or suspected to have been caused by another person. It may also be that of a person who was owed some property by someone at the time of death and the debtor failed to acknowledge or pay the debt to the surviving family members. The spirit may seek to exact compensation for wrongful death or non-payment of debt to surviving members of his or her family. A majority of indigenous Zimbabweans believe that the avenging spirit can express its displeasure by causing a disability in a member of the offending family. The belief is widespread that people with mental illness are possessed by an evil spirit (either malevolent or avenging).

Benevolent spirits are those of departed relatives (e.g., parents, grandparents). The spirit is often regarded as a positive influence in the family in that it is considered to look after all surviving members in its lineage. It is also believed to be the immediate link in long chain of ancestoral intercessors with God. People are supposed to keep themselves in a favourable light with the benevolent spirits by maintaining good family relations, looking after any property they may have left behind, and observing prescribed rituals (e.g., throwing an annual beer party for the family in rememberance of the departed ancestors). Breaking any of the basics of good conduct as just described could lead to punishment by a benevolent spirit or spirits. For instance, traditionalist Zimbabweans believes that indulging in adultery or incest could result a benevolent spirit causing a disability in the offspring of that liaison. A benevolent spirit could also allow visitation and harm on an individual by a malevolent spirit by withdrawing its protective functions. Thus, an individual may experience a disability causing injury or disease because he or she offended a benevolent spirit and was chastised for his or her waywardness.

From a Zimbabwean indigenous-traditionalist perspective, rehabilitation is regarded as the augmentation of social functioning though psychosocial and spiritual interventions involving the individual, extended family and the community. The spiritual interventions may well include herbal or medicinal plant treatment but, the belief is strongly held that the herbs on their own are not potent without the ancestral spirits guiding their selection and activating their active ingredients. Rehabilitation professionals in the indigenous-traditional (or non-formal) context is provided by families, traditional healers (also called herbalists, sangomas, traditional doctor, n'angas) and prophets of a Christian background. The World Health Organization (WHO) (1978) defined traditional healers as persons who use vegetable, animal, and mineral substances to treat a variety of acute or chronic conditions and are recognized by their communities as providers of health care.

The role of traditional healers in rehabilitation and health-service delivery was recognized by the Government of Zimbabwe by the passing of the Zimbabwe Traditional Healers Act in 1984, and following the formation of a national association of traditional healers in 1981 (i.e., The Zimbabwe National Traditional Healers Association: ZINATHA). As a measure of the esteem ZINATHA is accorded, the current president of the association is Professor of Sociology, and Former Vice-Chancellor (i.e., President) of the University of Zimbabwe, Dr. Gordon Chavunduka. ZINATHA also opened a School of Traditional Medicine in 1999 (Sunday Mail, 2001). The school is registered with the Zimbabwe Ministry of Higher Education and Technology, and offers certificate and diploma courses in traditional medicine. It collaborates with the University of Zimbabwe's Faculty of Medicine in the research on and teaching of traditional medicine.

A majority of members of ZINATHA work from their homesteads and provide health-care to about 80% of the population. A smaller number operate on a peripatetic basis. These include witch-hunters, rainmakers and some of the specialists in divination, intercessors with benevolent spirits and those skilled in the chastisement or expulsion of malevolent and avenging spirits. Traditional healers in Africa have a higher rate of success in the treatment of psychiatric disabilities rather than physical disabilities (Asuni, 1990; Levers & Maki, 1995).

Traditional healers levy a fee for their services. The fee is negotiable and may take into account the client's perceived ability to pay. Fees are higher for major jobs like expulsion of evil spirits rather than for minor jobs like divination. For example, expelling a malevolent spirit that is regarded as causing psychiatric illness in a family, the fee can be one herd of cattle and a cash allowance of about Z$5000.00 (US$100). This is a major cost to clients as the average client may earn about US$300 per year, although some clients may hold much more in assets (e.g., cattle, goats, sheep, and donkeys). Costs of divination services are in the equivalent of US$2 to US$10 in Zimbabwean dollars.

Prophets in Zimbabwe are often leaders of sectorial or church organizations that were founded by indigenous Zimbabweans. They claim to heal by divine command and aspire to biblical standards of treatment and cure (e.g., making the blind see, the deaf hear, and those with physical disabilities achieve full anatomical recovery). They share a turf with traditional healers in the domain of chastising evil spirits that they also regard as causing psychiatric disabilities and other disabilities. As a group, they are less organized vis-a-vis the traditional healers although they are highly esteemed rehabilitation and health consultants in their communities. Some prophets also serve a number of communities on a peripatetic basis. Most prophets levy a fee for their services much as members of ZINATHA do. A few of them provide free consultation, although clients are encouraged to give gifts to the prophet, which could be in the form of foodstuffs, clothing or cash.

Zimbabwean Modern View of Disability and Rehabilitation

The modern Zimbabwean view of disability is that it is a "physical, mental or sensory disability, which gives rise to physical, cultural or social barriers inhibiting (an individual) from participating at an equal level with other members of society in activities, undertakings or fields of employment that are open to other members of society" (Government of Zimbabwe Disabled Persons Act Chapter 17:01, 1996, p. 51). The modern Zimbabwean definition of disability draws from a number of historical and contemporary influences. First, Zimbabwe was a British colony from 1890 to 1980 and its colonial legacy included contemporary influences in the definition of disabilities. Second, the post-colonial Zimbabwean government was more sensitive to disability-related issues because of the need to rehabilitate thousands of returning war veterans following the conclusion of the 15 year long war of liberation against colonialism. The war veterans comprised mainly former freedom fighters who were waging a guerrilla war against the Rhodesian, White settler regime from neighboring Black ruled countries like Mozambique, Zambia, Botswana and Tanzania. In seeking to determine the prevalence of disability among the returning war veterans and civilian war veterans, a local (Zimbabwean) definition of disability was used. The post-colonial Zimbabwe government defined disability as "a physical or mental condition which makes it difficult or impossible for the person concerned to adequately fulfil his or her normal role in society" (Department of Social Services, 1982, p. 8). This definition of disability was consistent with the perception by the Zimbabwe an government that a majority of victims of the war of liberation had physical and mental disabilities.

Third, the equal opportunity phrase in the current Zimbabwean definition of disability can be traced to the extension of basic civil rights to people with disabilities by the post-colonial government. The war of national liberation from British colonialism was largely motivated by the denial of basic civil rights to Blacks. The negotiated political settlement that brought about the independence of Zimbabwe from Britain extended basic civil rights to the Black population. Therefore, and not surprisingly, the post-independence Zimbabwean government was more conscious and receptive to the civil rights of people with disabilities. As previously observed, a significant proportion of people with disabilities in post-independence Zimbabwe were war veterans who were former fighters of allied liberation movements that formed the national government at independence. People with disabilities who were not combatants also contributed to the national liberation effort and demanded that their civil rights be respected (Chimedza & Peters, 1999).

Fourth, the evolution of modern definitions of disability is also owed to the influence of international organizations for and of people with disabilities on the Zimbabwean disability-related organizations. A large number of organizations for and of people with disabilities in Zimbabwe were set up with the help of "sister" organizations from the developed countries. The Zimbabwean official definition of disability reflects, in part, the influence of organizations for and of people with disabilities from the developed world. Organizations like the Disabled Persons International, Council for the Blind, Canadian International Development Agency (CIDA), World Health Organization (WHO), Danish International Development Agency (DANIDA), UNESCO Sub-Regional Project for Special Education in Eastern and Southern Africa, Swedish International Development Agency (SIDA), Royal Commonwealth Society for the Blind (now called the Sight Savers), Horizon Trust, United States International Development Agency (USAID), and International League for Persons with Mental Handicap are among the international agencies significantly influenced disability-related policies and practices in Zimbabwe.

From a modern Zimbabwean perspective, rehabilitation is regarded as the restoration of lost physical, mental or sensory functions or their amelioration through medical and psychosocial interventions. It is aimed at circumventing or ameliorating the disability-related physical, cultural or social barriers to equal participation in society (Mpofu, 2001). Public and privately owned rehabilitation hospitals, schools, vocational training centers, and associations for and of people with disabilities comprise key rehabilitation service providers. These social agencies typically provide occupational therapy, physiotherapy and vocational training to people with disabilities. For example the Zimbabwean Ministry of Labour and Social Welfare provides grants for the vocational training of people with disabilities who are registered with training centers in the country. The Ministry of Health and Child Welfare has rehabilitation units at each of the 15 referral hospitals in the country. It also shares responsibility with the Ministry of Labour and Social Welfare for rehabilitation services provided at the nine national rehabilitation centers. In this connection, the Ministry of Labour and Social Welfare has responsibility over the administration and management of the centers as well as the vocational skills programs, whereas the Ministry of Health and Child Welfare runs the hospital within the rehabilitation centers. The Ministry of Labour and Social Welfare also manages the Workman's Compensation Fund (WCF). The WCF is an organization that was set up by the government in partnership with the private sector with the dual responsibility of providing vocational training to injured workers as well as administering their compensation claims. A majority of the large corporations in industry and commerce have rehabilitation departments for their workers. Organizations for and of people with disabilities are more involved with vocational and psychosocial rehabilitation than with occupational and physiotherapy.

Modern (or formal) rehabilitation services in Zimbabwe are manned by professionals with a variety of backgrounds: occupational therapists, physiotherapists, psychologists, clinical social workers, medical doctors, nurses, educators, and rehabilitation technicians. With the exception of the educators, these professionals are members of relevant professional councils that are registered with the Zimbabwe Health Authority. The Zimbabwe Health Authority regulates the qualifications and experience of all workers in the health sector. Educators typically work with children with disabilities in school settings, although some of them are involved with the planning and delivery of vocational training programs (Mpofu, Zindi, Oakland, & Peresuh, 1997).

Rehabilitation services in the formal sector are available for a fee. In the public sector, the fees are regulated by government and are currently set at about US$4.00 per visit. People who cannot afford the fee and can prove it are treated free of charge. Rehabilitation services in the private sector are considerably more expensive and set at a minimum of US$15.00 per consultation. These fees do not include additional costs for any specialized equipment or treatment regimens.

Rehabilitation Consultation Among Zimbabweans

As previously observed, Zimbabwe is a multiracial country with a recent British colonial history. Patterns of rehabilitation consultation vary by race and social class. White, Asian and middle-class Black Zimbabweans use the formal rehabilitation services much more than they do the non-formal rehabilitation services. Across race and social class, most Zimbabweans would consult the formal rehabilitation services in the case of acquired or traumatic disability or if the degree of disability is "sufficiently severe to become conspicuous" (Serpell et al., 1993, p. 5). Nonetheless, rehabilitation consultation behavior among Blacks transverses both the formal and non-formal rehabilitation services. For instance, Piachaud (1994) observed the following about urban communities in Zimbabwe: "within workshops organized for parents and workers in Harare it was possible to combine biological and spiritual explanations as well as solutions; a behavioral approach was not seen as contradictory to caring, to taking medication or visiting a spiritual healer" (p. 385). Formal rehabilitation services also tend to be more available in the urban than the rural areas (Mpofu, 2001). Therefore, there is widespread ignorance in the general population of the type and range of services offered by the formal rehabilitation services. This situation may be due to the fact that the formal rehabilitation services, which tend to be located in hospitals and other institutions, are less visible and accessible to clients as compared to services provided by the traditional healers and other professionals in the nonformal sector. As Chidyausiku (2000) observed "traditional healers were commonly seen as the main source of hope and (clients) often ignored or were unaware of other possible help and services" (p. 15). Traditional healers are also perceived as more credible and competent, ostensibly because their incorporation of core cultural beliefs about disability into treatment planning and delivery.

Another factor that militates against the greater utilization of rehabilitation services is that there is little referral of clients between rehabilitation professionals in the formal sector (e.g., medical doctors; psychologists) and those in the non-formal sector (e.g., traditional healers; prophets). Traditional healers and prophets are more likely to refer clients to medical doctors in the case of an apparent acute medical condition (e.g., fractured limb). Medical doctors and other professional in the Zimbabwean rehabilitation services are much less likely to refer a client to a traditional healer or a prophet. This may be due to the prejudice held by professionals in formal rehabilitation services against colleagues in nonformal structure (Mpofu, 2001). In addition, historically, traditional healers were not registered with the Health Professions Authority of Zimbabwe (Mpofu & Khan, 1997). This meant that the services they provided could not be paid for by medical insurance companies. Therefore, there was no legal or administrative framework for referrals between rehabilitation practitioners in the formal sector and those in the nonformal sector. Nonetheless, as Piachaud (1994) observed, clients often consult both the formal and nonformal rehabilitation service system either sequentially or simultaneously. Traditional healers and prophets are often the first port of call, and what they say may affect participation of and compliance with the formal rehabilitation services.

Lessons and Implications for Rehabilitation Practice in the US

Rehabilitation practices in the U.S. adhere primarily to the medical, scientific model. In essence, rehabilitation is viewed as a societal response to disability (Wright, 1980). While the Western system conforms to a dialectic process (e.g., the resolution of contradictory arguments), "the African system of consensus does not often present an `either-or' dilemma; more often `both can find accommodation" (Nicholls, 1995, p. 149). Nicholls observed that scientific knowledge is afforded intrinsic superiority and accepted as fact while indigenous beliefs are labeled primitive. Existing culture and disability literature is mostly the product of research of North America and Europe (Armstrong & Fitzgerald, 1996). Armstrong and Fitzgerald further emphasized the significance of examining rehabilitation activity in Africa to broaden the base of cross-cultural comparison and conceptual development. Those who ascribe to traditional and those who ascribe to formal methods acknowledge a need for collaboration (Green, Benshoff, & Harris-Forbes, 2001; Nierenberg & Shelson, 2001). Because of the increased attention to traditional and/or spirituality in counseling and the role it plays in the lives of individuals Nicholls suggested the application of "pragmatic spirituality" (e.g., a matter-of-fact way of creating solutions) instead of superstition (connotes bondage to ignorance). Given that spirituality [and superstition] exist in Africa and the U.S., individuals' perception of disability and its causation can be influenced by reciprocal effects of the two, thus promoting accepting and enabling attitudes toward disability (Nicholls, 1995).

Global applicability and utility of ethnorehabilitation was examined by Levers and Maki (1995) in response to shifting paradigms away from the "absolute hegemony of scientific method and Cartesian logic as the only valid dictum of knowledge" (p. 127). Exploration of ethnorehabilitation is important because it helps to decrease counselor insensitivity to cultural differences. Cultural insensitivity to differences in language, values, habits, and definitions can lead to diminished counselor empathy, misunderstandings with their consumers, and misdiagnosis, thus interfering with the establishment of rapport and trust with consumers (Rubin, Pusch, Fogarty, & McGinn, 1995). Overwhelmingly, the U.S. is guided by "technocratic" (e.g., technology, meritocracy) priorities in which power is knowledge or technical expertise obtained through education is the guiding principle as opposed to spiritual values (McCarthy, 1995). Although technocratic priorities are central to disability services in the U.S., certain aspects of spirituality are shared by established religions and Native religions (e.g., rituals, persons are three-fold, and life is eternal) (Locust, 1995) exerting some influence on values, beliefs, and practices of individuals.

"The reciprocal, interweaving influences of culture, spirituality, religion, and diversity within cultures" serve as moderators of individuals' attitudes, perceptions, and responses to disability and intervention (Havranek, 1999, p. 34). The prominence of these influences is particularly strong among racial minority groups in the U.S. and share philosophical characteristics of African beliefs. For example, African Americans, Native Americans, and Hispanic/Latino Americans have philosophical and cultural beliefs about illness and disability that are rooted in nature and spirituality (Mpofu & Beck, 2000; James & Johnson, 1996; Locust, 1995). Most Native Americans have ten spiritual beliefs that are most common, and those pertaining to illness/disability include (a) a person is a three-fold being made up of a spirit, mind, and body, (b) illness affects the mind and spirit as well as the body, (c) wellness is harmony in spirit, mind, and body, and (d) unwellness is disharmony in spirit, mind, or body (Locust, 1995). Because Native Americans see harmony as a part of spirituality, and if a person acquires a disability, it might indicate that his or her harmony was not strong. Therefore, "only a well-seasoned native spiritual leader can discern the true cause and indicate a path for healing" (Locust, 19995, p. 208).

In another example, the African American church developed in response to the needs of African Americans who retained a belief in the harmony of spiritual and physical life (Washington & Beasley, 1988). Today the African American church continues to function as an institution that affects the psychological and social health of African Americans (James & Johnson, 1996). Similarly, Hispanic/Latino Americans interpreted the experience of illness and disability as "susto" growth enhancing spiritual experience that is best mediated by rehabilitation experts such brujas or shamans (Rubel, 1984). Hispanic/Latino Americans of a Roman Catholic religious background are also more likely to ascribe spiritual interpretations to the experience of disability and rehabilitation (Mpofu & Beck, 2000). Countless other examples can be offered across various religious and ethnic groups, but space limitation does not permit for such an expansive discussion. These are only a few examples demonstrating parallels between Zimbabwean and other minority groups in the U.S. regarding perceptions on disability and are not intended to inclusive and exhaustive.

Traditional, nonformal, and spiritual methods intervention have produced some amazing influences on a variety of physical phenomena (McCarthy, 1995). Havranek (1999) offered seven ways that counseling with a traditional and/or spiritual component can help consumers (see Havranek for specific ways). McCarthy acknowledged that while metaphysical processes may require practice and guidance to perfect, it is equally important to acknowledge that these methods are "(a) often useful even in their uncultivated state, (b) always available, and (c) independently accessible to each person, regardless, of physical limitations, socio-economic status, or other potentially restricting characteristics" (p. 88). Given these considerations, application of Zimbabwean traditional approaches offer several applications for rehabilitation practice in the U.S.

First, African indigenous healers serve as mediators between the persons with disabilities and the ancestors who are invoked in the healing process and mediate with God. This link, in part, is a spiritual one (Levers & Maki, 1995). Spirituality is recognized as an important dimension of the healing/recovery process (Piedmont, 2001; Trieschmann, 2001; Vash, 2001). Therefore, Trieschmann recommended that the western professional audience consider utilization of spirituality as "guidelines for personal transformation which have the mental, emotional, and physical benefits of improved mood and sense of well being, resulting in an improvement in physical function and health" (p. 28). Although this is the personal, experiential, and subjective aspect, the subjective is a frequently overlooked part of an individual's identity. In other words, the subjective and objective occur simultaneously and are equally important in serving persons with disabilities because the exclusive reliance on the objective, physical, and quantitative aspects of life has been the major failure of health care and rehabilitation systems (Trieschmann, 2001).

A second consideration is for rehabilitation service providers to capitalize on the wisdom, knowledge, and expertise of community or lay persons who interact with their consumers (e.g., family elders, religious/spiritual leaders). These persons may be able to provide insight, or at least explanation, of consumers' willingness or unwillingness to participate in and cooperate with fulfilling the goals of their individual plan for employment (IPE). Because these persons are respected in the community and by the person with a disability they are able to help establish rapport and mediate trust between the consumer and service provider. In addition, these individuals usually have historical knowledge of the persons with a disability that may clarify inconsistencies between what is observed and what is known.

Finally, the most evident theme that comes across in the incorporation of traditional or indigenous practices in western rehabilitation is viewing rehabilitation as holistic. Traditional healers regard people as people and western practices have forgotten the total human being (Levers & Maki, 1995). "Etymologically, there is a direct connection between holistic thinking and concerns about medical matters" (McCarthy, 1995, p. 90). Moreover, the holistic perspective is increasingly important when working with cultural minority populations. A key supposition to the holistic approach is that effective counseling is individualized and an emphasis should be on understanding what is beneficial or meaningful to the consumer as a person, rather than viewing the person only as a representative of a certain racial/cultural group (Stebnicki, Rubin, Rollins, & Turner, 1999). Ironically, at some point during the evolution of rehabilitation the practice of articulating the consumers' values and beliefs was either lost or ignored.

Counselors can incorporate parables to get ideas across to consumers and increase communication (Havranek, 1999). Storytelling and art are representative of spiritual communication and have proven to be effective means of communicating with consumers who hold to more traditional beliefs and practices (Nicholls, 1995). Regardless of the means employed, traditional or spiritual approaches are incomplete unless they transform awareness into action for both consumers and counselors (Havranek, 1999).

Conclusion

Definitions of disability vary across cultures. Although formal or scientific approaches to rehabilitation have proven value, indigenous or traditional African practices have demonstrated numerous benefits to those who believe and trust in them. Moreover, unlike with scientific approaches, cost is not a prohibitive factor in either the acquisition or application of traditional techniques. Thus, traditional African methods of responding to disabilities offer several benefits to western formal or scientific approaches to rehabilitation. In both values and practice, the way in which rehabilitation in the U.S. is most likely to be affected by spirituality, nonformal techniques, and traditional practices will be determined by the rehabilitation field's acceptance or rejection of non-scientific and nonformal therapeutic interventions that have been imported from non-Western cultures (McCarthy, 1995). The key to successfully integrating traditional methods in rehabilitation practices in the U.S. is for practitioners and rehabilitation educators and researchers to recognize the credence of capitalizing on and infusing traditional approaches into practice.

In conclusion, the sentiment of continuously exploring and expanding options in rehabilitation practice in the U.S. was summarized by Nicholls (1995) to include several important justifications for using traditional rehabilitation approaches. These include: (a) rehabilitation professionals must remain open to paradigms from other cultures, (b) avoidance of the extinction of human skills, and (c) systematically examine indigenous systems and conserve the positive features.

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Elias Mpofu
The Pennsylvania State University and University
of Zimbabwe

Debra A. Harley
University of Kentucky

Elias Mpofu, Ph.D., CRC, The University of Pennsylvania, 327 CEDAR Building, University Park, PA16802-3110. Email: [e-mail]