the status of rehabilitation services in canada

The Status of Rehabilitation Services in CanadaAuthor(s): EDWARD DUNLOPSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 54, No.5 (MAY 1963), pp. 193-201Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41983049 .

Accessed: 12/06/2014 14:45

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at .http://www.jstor.org/page/info/about/policies/terms.jsp

.JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range ofcontent in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new formsof scholarship. For more information about JSTOR, please contact [email protected].

.

Canadian Public Health Association is collaborating with JSTOR to digitize, preserve and extend access toCanadian Journal of Public Health / Revue Canadienne de Sante'e Publique.

http://www.jstor.org

This content downloaded from 195.34.79.223 on Thu, 12 Jun 2014 14:45:05 PMAll use subject to JSTOR Terms and Conditions

http://www.jstor.org/action/showPublisher?publisherCode=cpha

http://www.jstor.org/stable/41983049?origin=JSTOR-pdf

http://www.jstor.org/page/info/about/policies/terms.jsp


Canadian Journal of

PUBLIC HEALTH

VOLUME 54 MAY 1963 NUMBER 5

The Status of Rehabilitation Services

in Canada1

EDWARD DUNLOP,2 O.B.E., G.M., B.A.

EFFECTIVE the behavioural techniques

sciences are

for now

the available successful

within rehabilitation

medicine, of education a substantial

and the behavioural sciences for the successful rehabilitation of a substantial

majority of the disabled, particularly the physically disabled. The crucial problem now confronting us is how to organize our social institutions to ensure that these rehabilitation techniques will be readily available to the disabled who need them. In the development of rehabilitation methods, the record is bright, if not brilliant; in their widespread application, the record is lustreless, even dark.

It is my purpose to examine the extent of our failure to provide comprehensive rehabilitation services in Canada, and the reasons for that failure. I shall then suggest how the situation can be remedied, and discuss some of the contributions which the public health movement can make.

Extent of Failure To what extent have we failed? This question could be answered with assur-

ance only if we had an accurate estimate of the numbers of disabled persons who cannot obtain the rehabilitation services they need. Unfortunately, with the exception of some very limited surveys, we have no precise information. The Canadian Sickness Survey informs us about the widespread extent of physical disability - that there are 963,000 Canadians disabled to some degree, of whom 423,000 are reported as being totally or severely disabled. It tells us nothing about the numbers of the disabled who have successfully accomplished their rehabilitation, or the numbers for whom rehabilitation is impossible.

Presented at the 53rd annual meeting, Canadian Public Health Association, held in Toronto, May 28-31, 1962.

2Executive Director, Canadian Arthritis and Rheumatism Society, 900 Yonge Street, Toronto 5.

193



194 CANADIAN JOURNAL OF PUBLIC HEALTH Vol. 54

We must turn to other than statistical measures, such as the eligibility characteristics of existing programs, and the empirical estimates made in countries with greater experience. Restricted Eligibility. Traditionally, comprehensive rehabilitation programs have been developed to meet the needs of particular categories among the disabled for whom some governmental or voluntary agency has perceived a special responsibility - the industrially disabled, the disabled veteran, the blind, the paraplegic and the tuberculous. So long as we are discussing comprehensive rehabilitation services, then I am afraid the list of favoured categories cannot be extended much beyond these few. The word ''comprehensive" is significant when it is used to describe the terms "rehabilitation services" or "rehabilitation program". Any act - a surgical operation, vocational training, job placement - even the offer of a regular ride to work - may be regarded as a rehabilitation service when it contributes to the rehabilitation of a disabled person who needs just that service. In this limited sense, we can say that rehabilitation services are quite generally available throughout Canada. Indeed, this may partly account for the large numbers of disabled people who have accomplished their own adjustment to life and to work without the apparent assistance of any organized rehabilitation program.

An organized program whose primary responsibility is the rehabilitation of the disabled cannot, however, rely upon the fortunate chance that some particular service or services at its disposal will accomplish the rehabilitation of its clients. The range of services at its disposal must be as broad as the diverse physical, mental, social and vocational needs its clients may present - in a word -

comprehensive. Where only one or a few rehabilitation services are available, a high rate of failure is the consequence.

A number of agencies provide specific rehabilitation services, such as training, physical restoration or sheltered employment. I think it may be concluded, however, that the traditional pattern remains - that disabled persons in Canada are eligible for comprehensive rehabilitation services only insofar as they are representative of particular categories - the industrially disabled, disabled veterans, the blind, the paraplegic and the tuberculous. The generality of this propo- sition has been modified only slightly by the recent and commendable efforts of a number of community and governmental agencies to provide comprehensive rehabilitation services for the disabled regardless of category. Comparisons with U.S.A. In the United States, the Office of Vocational Rehabili- tation, a Division of the Department of Health, Education and Welfare, has had 40 years' experience in the administration of the Federal-State Vocational Rehabilitation program. By what appear to be empirical means, they have estimated that about 1,250,000 Americans need rehabilitation. While they are providing rehabilitation services to about 100,000 disabled people annually, they estimate that they should rehabilitate 250,000 a year if they are to reduce the backlog and meet the needs of the annual increment to the ranks of the disabled. If we were to translate these estimates into Canadian terms by the usual mathematical device, we would find 125,000 Canadians needing rehabilitation. Moreover, we would now be rehabilitating 10,000 people a year, and our target would be 25,000 annually.



May 1963 REHABILITATION SERVICES 195

The only Canadian programs in any way comparable to the Federal State Rehabilitation Program have been developed in most provinces under agreements entered into between various departments of provincial governments and the Federal Department of Labour. Under this program, 1,600 disabled persons were rehabilitated during 1961. In passing, it is interesting to note that these 1,600 people received about $1,000,000 a year in public assistance prior to rehabilitation, whereas they are now earning their living at a rate of $3,000,000 a year, a clear illustration of the economic benefits of rehabilitation. It is recog- nized that these 1,600 rehabilitants do not necessarily include the rehabilitants of other programs, Workmen's Compensation, voluntary agencies and the like. Neither do the United States figures earlier quoted. Thus our achievement of 1,600 rehabilitants contrasts most unfavourably with targets such as 25,000 or even 10,000.

It may be safely concluded that the extent of our failure to provide comprehensive rehabilitation services for disabled Canadians is very great.

Reasons for Failure What are the reasons for our failure? These are complex, interrelated and

difficult to isolate. It has seemed to me that the high degree of success achieved in Canada in

the rehabilitation of the most obvious categories - the industrially disabled, the disabled veteran, the blind, and the paraplegic - has caused us to overlook the less obvious needs of the remainder of the disabled. Those who formulated public policy saw that the rehabilitation movement was going well, but failed to see that it was not going well in all quarters.

Our concentration upon employment in the competitive labour market as the most desirable rehabilitation objective for the industrially disabled and disabled veterans may have blinded us to the rehabilitation needs of other disabled people. Perhaps we overlooked the housewife whose objective was to return to her place at the center of her family life, or those for whom employment in

economically sheltered circumstances is their highest goal. There are also those whose rehabilitation objective is the mastery of the simple activities of daily living, such as turning over in bed, dressing themselves and going to the bath- room without assistance. We may not have thought of these people as having rehabilitation needs, and we may not have thought of rehabilitation techniques as being capable of contributing to the solution of their problems.

Perhaps many of us regarded the rehabilitation responsibilities of the State as

being limited to the industrially disabled and the disabled veterans, and felt that the rehabilitation of other categories should be left to the voluntary agencies. If so, then we failed to recognize - as I believe we now do recognize - that the magnitude of the rehabilitation task far exceeds the capacity of unaided

voluntary effort. Imprecise Location of Governmental Responsibility. I think the greatest reason for our failure - which is relative rather than absolute - has been the difficulty of locating rehabilitation responsibility among departments of government and between levels of government. So far as the disabled individual is concerned, his rehabilitation is a continuous and indivisible process which stubbornly




refuses to divide itself into segments in accordance with the neat functional distribution of responsibility among government departments.

Several departments or agencies of provincial governments have obvious concern in the rehabilitation of the disabled: Departments of Health, Education and Public Welfare, plus Workmen's Compensation Boards and Hospital Ser- vices Commissions. Lack of precise location and clear definition of the nature and extent of ministerial and departmental responsibilities has often led to confusion, and consequent dilution of leadership. Until quite recently, similar confusion as to the location of ministerial and departmental responsibilities was equally evident within the Government of Canada, and it may not yet be entirely dissipated. Shortcomings of Federal Measures. Our constitution quite clearly places rehabilitation for the disabled within the jurisdiction of provincial governments. A pattern of financial responsibility divided between the federal and provincial governments has become established in recent health and welfare programs. Accordingly, the provinces have looked to the federal government for financial assistance in the development of new rehabilitation programs. In their view, this financial assistance should be assured over a period of years (as it is in the Old Age, Disabled Persons and other Assistance Acts), and the federal government should bear 50% of the costs. With the exception of vocational training made available under the Technical and Vocational Training Assistance Act, the other main sources of federal funds for rehabilitation - the Medical Rehabilita- tion and Crippled Children's Grant and the Co-ordination of Vocational Rehabili- tation Agreements Order - failed to meet these criteria. Useful as these measures may have been, they were ineffectual vehicles for launching comprehensive rehabilitation programs for the disabled. As a result, except for rehabilitation programs which are entirely funded provincially, such as those of Workmen's Compensation Boards, the rehabilitation programs of provincial governments have thus far remained in a rudimentary state, restricted almost entirely to the provision of rehabilitation counselling and vocational training.

More Promising Prospects How can the situation be corrected; how can we ensure that comprehensive

rehabilitation services are made available to all disabled Canadians who need them? It has long seemed to me that this high purpose can be achieved only when our society adopts a new social principle, which may be stated thus: that the opportunity to emancipate himself from the needless consequences of disability should be the right of every disabled person. Education, we may recall, remained the prerogative of a few favoured categories until the principle of universal popular education was accepted, and guaranteed by state action.

After 17 years of close observation of the rehabilitation scene in Canada, I had begun to despair that this principle - or anything approaching it - would ever become public policy. Just about one year ago, the outlook became more hopeful. The significant event was the enactment of the Vocational Rehabilita- tion of Disabled Persons Act by the Parliament of Canada. This Act has a number of important features. It provides for a comprehensive rehabilitation




program, just as comprehensive as provincial governments may choose to propose. It provides the desired assurance of continued federal participation, and assurance that the federal participation will be a full 50% of the costs of the program. As a result, we find that six provinces - Alberta, Manitoba, Ontario, New Brunswick, Prince Edward Island and Nova Scotia - have recently signed the necessary agreements pursuant to this Act. They are now in a position to launch comprehensive rehabilitation programs for their disabled residents, regardless of their category. The Vocational Rehabilitation for Disabled Persons Act. As its title implies, the new Act is vocational in its objectives. A disabled person means: "person, who because of physical or mental impairments is incapable of pursuing regularly any substantially gainful occupation". Similarly, the rehabilitation services which may be made available under the Act are to be provided only to those who require them in order to become: "capable of pursuing a substantially gainful occupation". The definition of a substantially gainful occupation is of central importance. Peculiarly enough, this important definition is not found in the Act, but in the Agreements made pursuant to the Act. In these Agree- ments, a substantially gainful occupation is defined thus: "employment in the competitive labour market, the practice of a profession, self-employment, home- making or farm work (including work where payment is in kind rather than in cash), sheltered employment, home industries or other homebound work of a remunerative nature".

Although the definition stresses the vocational objectives of the Act, it is reasonably broad, at least broad enough to embrace the rehabilitation of the disabled housewife and homemaker.

It is important to understand that, despite the vocational objectives of this program, the rehabilitation methods to be employed are not restricted to the vocational sphere and may embrace all the rehabilitation services most regularly required, including those usually described as medical rehabilitation or physical restoration.

In my view the new Vocational Rehabilitation for Disabled Persons Act, its companion agreements and provincial legislation, are the most important instruments which have yet been forged in the rehabilitation field in Canada. We should use these instruments with skill and understanding to shape rehabilitation programs of the highest order. Clarifying Relative Responsibilities of Government Departments . If these expanded programs are to be successfully launched, now is the time to clarify the relative responsibilities of the different departments and agencies of the provincial governments, so as to locate responsibility with precision and do away with the confusion now so evident.

Although many departments of government, and many non-governmental agencies, contributed essential services to the rehabilitation of disabled veterans, the responsibility to ensure that disabled veterans received the rehabilitation services they required was clearly vested in the Department of Veterans' Affairs. The same can be said of Workmen's Compensation Boards in their rehabilitation relationships with the industrially disabled. I mention this because it gives us a




clue to a useful administrative distinction which can be drawn between different kinds of rehabilitation program responsibilities. These can be divided into two main classes :

1 . Client-centered programs, 2. Service-centered programs.

These two kinds of programs are sometimes mixed. While the Department of Veterans' Affairs program for the rehabilitation of the disabled was primarily client-centered, it did, for example, operate its own hospitals - a service-centered program.

The vocational training provided by the various educational authorities is

primarily a service-centered rehabilitation program. At the same time, the

special education activities of departments of education, particularly as exempli- fied in their schools for the deaf and the blind, may be described as both client centered and service-centered.

In seeking to gain a clear picture of the situation in any particular province, it is a useful exercise to draw up two lists of government rehabilitation programs, one headed client-centered and the other headed service-centered. On the list of client-centered programs there should be three headings: Department or

Agency, Client Category, Scope of Program. Under the appropriate headings should be set down a succinct resumé of the

rehabilitation programs of each relevant department or agency. Two examples might be:

Department or Agency Workmen's Compensation

Board

Department of Health

Client Category Persons disabled by industrial accidents or disease

Persons disabled by tuberculosis, mental illness, epilepsy and mental retardation

Scope of Program Comprehensive

Comprehensive within certain tuberculosis sana- toria, mental hospitals and hospital schools; restricted beyond these institutions to counselling services, plus such other specific rehabilitation services as clients may secure from other governmental and non-governmental agencies.

On the list of service-centered programs there would also be three headings which are shown below, along with two possible examples:

Department or Agency Department of Education

Hospital Services Commission

Service Vocational training, through institutions operated or supervised by the department

Standard ward care and diagnostic services

Scope To the extent requested by the Department of Public Welfare and paid for under the Technical, Vocational and Training Assistance Act.

Insured patients

Once this process has been completed, the outlines of the actual situation begin to emerge. It becomes possible to settle rationally the precise location




of new responsibilities, and the relocation of existing responsibilities. These may have to be defined or re-defined by statute or order-in-council.

The examples which I have given are hypothetical and quite incomplete, and I have not attempted to sketch the nature, scope and location of the new vocational rehabilitation programs now being developed as a result of the Vocational Rehabilitation for Disabled Persons Act, and its companion Agree- ments. These may differ from province to province. The important thing is to see where these new activities should fit into a total, expanding and changing program for the rehabilitation of the disabled residents of each province.

The Rehabilitation Role of Public Health What are the contributions which public health can make to the rehabilitation

movement? The main responsibilities of public health appear to be twofold. One is concerned with the provision of direct services, that is treatment for specified classes of sick people, usually under clearly defined statutory authorities. These classes include the mentally ill, the tuberculous, some among the retarded, the addicted and the epileptic. The other responsibility of public health concerns the prevention of disease. Rehabilitation and Traditional Treatment Responsibilities. It has frequently been said that rehabilitation is the third phase of medicine, the others being preventive and curative. I suggest that a high standard of medical care does not permit such arbitrary distinctions. Thus, as part of its responsibility for the treatment of certain classes of sick people, public health has a duty to provide them with the best possible rehabilitation services. So long as these patients remain under the care of institutions operated or supervised by public health authorities, it is logical that whatever rehabilitation services they require should be provided through these institutions. When patients are no longer under the care of these institutions, and have returned to the community, it is a question whether their rehabilitation should continue to be the responsibility of the public health authorities, or should be transferred to other rehabilitation agencies. This question cannot be answered with assurance at this time, and depends upon the quality and objectives of the general follow-up program for those who have been discharged from such institutions, and the quality and characteristics of the other rehabilitation programs available within the province. A combination of both approaches is likely, the critical consideration being the particular needs of the discharged patient in relation to the specific resources of the programs available. Rehabilitation and other Responsibilities. Rehabilitation is not the prevention of disease, but its objective is the prevention of the needless consequences of disability, either through its intrinsic reduction or elimination, or through the extrinsic amelioration of its socio-economic effects. The theme of this meeting is "Change and Challenge". It is not inappropriate, therefore, to consider the possible extension of the traditional horizons of public health to embrace some part of the responsibility for ensuring the existence, adequacy and effectiveness of comprehensive rehabilitation programs for the disabled generally.

Rehabilitation is defined as the process of assisting the disabled to attain the best possible physical, mental, social, vocational and economic adjustment and



200 CANADIAN JOURNAL OF PUBLIC HEALTH Vol . 54

usefulness of which they are capable. Although rehabilitation is a process, it has nothing in common with uniform and ordered industrial processes in which certain materials are subjected to an unvarying sequence of identical operations and procedures. Like the able-bodied, every disabled person is a unique com- pound of training, experience and attitude. He is a member of a family and a community which may help or hinder his bid for independence, and may govern the choices before him.

Each disabled person must select a rehabilitation objective which is suitable to his own peculiar situation and needs. A rehabilitation plan must be con- structed for him which brings the required services to bear where and when necessary. If the rehabilitation process is to succeed, it must never be forgotten that the disabled person is himself the principal architect of his design for living. Those who provide the rehabilitation services are the advisers and the technicians, who contribute their skill and experience to ensure the soundness of the edifice and to make its construction a reality.

I have described the rehabilitation process in this much detail to emphasize its highly individual character. The successful rehabilitation of substantial numbers of disabled people will not flow simply from the provision of a broad, comprehensive and flexible range of services. These services must be adminis- tered in a manner which treats each disabled person as an individual, and ensures the indivisibility of the process for that individual.

Adherence to the principle of the individual approach on the part of various professions and institutions can achieve maximum effectiveness only when the essential indivisibility of the total rehabilitation process is provided for. Some one person and agency must be placed in a position to maintain a continuous view of the individual's total rehabilitation. This necessitates the creation of an administrative mechanism which has, among other things, a sufficient staff of skilled case workers. In the rehabilitation field such case workers are usually known as rehabilitation counsellors. The rehabilitation counsellor should be an expert in understanding how the related services of the many professions contribute to the solution of the problems of the disabled. He must recognize the nature of the problems faced by the disabled individual, assist him to secure the services he needs, guide him through the processes of rehabilitation, and maintain contact with him after the services are completed. If public health were to assume responsibility for the rehabilitation of the disabled generally, then it would have to equip itself with legislative authority to purchase or provide a comprehensive range of rehabilitation services, and the administrative machinery, including a sufficient number of rehabilitation counsellors, necessary to meet the rehabilitation needs of the disabled on an individual or "client centered" basis. There is no inherent reason why this could not be done, although it would run counter to the emerging pattern in most provinces. In the United States, responsibility for the rehabilitation of the disabled generally is assigned to State Boards of Education. In the United Kingdom, it is assigned to the Department of Labour and National Insurance. The matter of greatest importance at this stage in Canada is not what department should be responsible, but to know which department is responsible.

Responsibility for the prevention of disease is shared between practising




physicians in their relations with individuals on the one hand, and public health in its relations with social units on the other. Perhaps responsibility for rehabilitation services will follow a similar pattern. In that case, the rehabilitation responsibilities of public health would be a part of its relationship with social units, schools, communities and community agencies, individual or client centered responsibilities being assigned elsewhere. Public health authorities could play several roles of great importance: ( 1 ) Case finding and referral. The activities of public health nurses particularly

make possible important contributions to the case finding process. When a case is found, each local public health authority should be capable of referring it to the most appropriate rehabilitation agency.

(2) Provision of information. Local public health authorities should be able to provide information about all rehabilitation programs within their area, thus facilitating the work of all health professions and agencies in relating the needs of their patients or clients to the services available.

(3) Public education. Public health authorities are in close communication with many of the groups which assist in formulating public opinion and policy. They can assist greatly in creating a favourable environment in which rehabilitation activities can flourish.

Conclusion If the foregoing are to be the main responsibilities of public health in the

development of expanding rehabilitation programs, then the corollary is that the appropriate machinery to ensure the provision of rehabilitation services for disabled individuals, i.e. client-centered programs, must be located in some other department of government, as appears likely to be the case. If adequate client-centered machinery is not created, then all the case finding, referral and information activities developed by public health authorities would be of little avail.

If Canada is to develop comprehensive programs for the rehabilitation of its disabled, then clear, overall and unimpassioned planning is necessary to deter- mine the relative responsibilities of each department or agency of government concerned and of the voluntary agencies. There is important work to be done -

enough for all.

CHANGING ACCENTS IN COMMUNITY DISEASE The health activities of the day relate in

this country primarily to the chronic diseases of degenerative, metabolic, and neoplastic nature which are brought into prominence by an aging population and an improved control of infection.

The mass diseases of current times are mainly man-made; their sources reside to a large extent in characteristics of the host and in the social environment. This contrasts with the prevailing natural origins of disease in former periods and their strong connec- tion with the external environment. The approach to prevention and control is there-

by altered. An individualized effort is sug- gestively more productive, because active co-operation of the person concerned becomes close to essential. In some situations, the individual can no longer depend on society to provide preventive measures, but must possess the knowledge to fend for himself. As a result, public health education acquires added significance.

John E. Gordon , M.D., F.A.P.H.A. American Journal of Public Health Feb. 1963 , Vol. 53, No. 2



the status of rehabilitation services in canada

Documents