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South African Exploratory Trip

Exploratory Trip to South Africa
Program in Speech Language Pathology
Teachers College, Columbia University
March 13 to March 27, 2008
Lesley Wolk, Catherine (Cate) Crowley, and Caitlin Ruderman 
Written by Cate,

Saturday, March 15, 2008
Visit the Apartheid museum and tour the Soweto township.
We could not have chosen a better way to spend the first morning of our first day than by visiting the Apartheid Museum in Johannesburg. It puts so much of South Africa’s current challenges into perspective. From 1948 to 1994, apartheid was in place and the country was ruled by a party elected by just ten percent of the population. Nelson Mandela was only released from prison in 1990 and the first democratic election in South Africa took place in 1994. Through videos, photos, and written descriptions, we witness the injustices inflicted on all but the “white” population of South Africa. The experience is moving and profound, and raises very similar feelings to those that Cate experienced at the Martin Luther King, Jr. National Historic Site in Atlanta, Georgia. The photo of the boy at left--desperately eager to acquire an education during apartheid--speaks to the continued need for us to work to achieve access to quality education for all.

Our guide for the tour of the Soweto township is a man who lived there during the 1976 uprisings through the end of apartheid. The 1976 Soweto uprisings against apartheid are seen as the catalyst for the movement that finally brought down that system in 1994. The uprisings were in response to a new language policy that the ruling party had decided to impose. That policy was to mandate Afrikaans as the language that would be used in the schools. Afrikaans is a language derived from Dutch and was the language of the majority ruling party that imposed the apartheid system. Afrikaans is only spoken in South Africa. Its use in the schools would restrict the future opportunities of the black community and require them to speak and learn in the language of their oppressors. The school children saw this and took to the streets to demonstrate against the policy. The government responded with gunfire and killed two children. The photo of Hector Pieterson--a 13-year-old killed that day--galvanized the world’s attention on South Africa’s oppressive policies. The movement continued to be forcefully and violently opposed by the ruling party, but it continued until apartheid was finally ended in 1994.

The effects of apartheid on the country and the dramatic changes post-apartheid continue to dominate the media and many of our discussions with South Africans. The pandemic of HIV/Aids here has its roots in the time when apartheid was in place.    

March 16-18, 2008 Kwazulu Natal: Portshepston and Murchinson areas

The Kwazulu Natal area is around the city of Durban in the eastern part of the country. The people here are predominantly Zulu. The Kwazulu Natal region has one of the highest percentage of HIV/Aids anywhere in the world, with estimates as high as 44 percent of the population infected in certain areas.  

We stay in the volunteer lodgings at a children’s community called “Rehoboth.” The name comes from the Book of Genesis 26:22 “Now the Lord has given us room and we will flourish in the land”. Those who work in Rehoboth are Christians and believe that God provided space in order for the children who live at Rehoboth to flourish and reach their full potential. 
A Dutch couple, Alfons and Ivonne van der Galien, have lived at Rehoboth for seven years building a community for children with HIV/Aids who have been orphaned by Aids. Rehoboth has accommodations for the directors and staff and for approximately 8 volunteers. Over the past seven years they have built 11 cottages, which are two-bedroom fully equipped homes, and a preschool--or crèche--for the children too young to attend the local schools. In addition there are playgrounds and gardens and macadamia nut trees, three big dogs and a white horse named Fudge, so the place looks like the garden of Eden.

We walk to one of the cottages and meet the “house mum” and her four children. The “mums” or “aunties” are selected for their love of children, and their ability to take care of the children. The mum we meet in this cottage has four children--ages 10 months, and 3, 6 and 10 years old, a typical grouping at Rehoboth reflecting the age ranges of a typical family. Lesley and the mum sing a Zulu lullaby together. Then the mother must give the baby a nebulizer treatment. The baby is uncomfortable, and Cate shows the mum how she can use the lullaby to calm the baby during her treatments. The mum is very open and incorporates it into the treatment. Cate and Lesley are especially happy to see how lovingly the mum interacts with the children.

The first evening we are treated to a “braai”, a South African barbecue. We learn a great deal about Rehoboth as we spend the evening with Alfons and Ivonne, Sophie, an American volunteer, and Leo O’Connor. Leo works with churches and charitable organizations in the U.S., Europe, and South African to ensure that their donations are well spent and that the places like Rehoboth get their needs met. We watch a newly created video on Rehoboth and are struck by the “before” photos of some of the children we have met. In the videos the children look like they are in the final stages of life, yet when we meet them in person they are robust, glowing, happy children. Ivonne and Alfons tell us that all of the children are diagnosed with HIV/Aids and almost all arrive in very bad physical shape. Initially, Alfons and Ivonne thought Rehoboth would be more like a hospice for the children, but with good nutrition and medical care, and loving and nurturing adults the children have flourished physically and emotionally. Ivonne and Alfons also attribute the transformations to the Christian work at Rehoboth. Anti Retral Virus (ARV) drugs only became available to the children one year ago and the mums are trained how to administer the drugs for maximum effectiveness.

During the evening we talk in detail about the choice of languages to use with the children. Because English is the language of education in South Africa, Ivonne and Alfons are interested in hearing about the current research on bilingualism especially with children with language delays. We talk about how the discussion changes depending on whether the mums can provide good English language models and the effect on self esteem when the use of a child’s first language is discouraged. We talk about possibly having the English-speaking volunteers spend time with the mums so that their proficiency can improve. We also talk about continuing to use Zulu by the mums that do not have good proficiency in English and to encourage the continued use of Zulu with the children even as they acquire English. Cate offers to consult on a regular basis with Ivonne and Alfons on bilingual issues for the community, an offer that is gratefully accepted.   

Weekdays at 7:00 a.m. the school age children are driven to school in the Rehoboth vans. At 8:00 the mums and their two younger children and the staff and volunteers gather for devotions. Devotions begin with the mothers singing a capella Zulu gospel songs which are gorgeous. Then someone leads the devotion, usually by one of the directors. The talking and reading part is about 10 minutes long and it is immediately translated into Zulu. During devotions the children sit on their mums’ laps or wander around quietly.   

The preschool, or crèche, has two parts-the baby crib for children birth through 3 and the older crèche for children 3 to 5. The crèches have most of the toys, activities, table, and chair setups that we would expect to find in a head start or good preschool program.  Much focus on shapes, colors, body parts—but that is true in most preschools. The crèches are taught by one of the volunteers.

We volunteer to lead the crèche both mornings. Cate brought eight big books which were not the easiest carry on luggage to manage on the long journey; but the children’s responses make it all worthwhile. They love the Eric Carle books From Head to Toe, The Very Hungry Caterpillar, and Brown Bear Brown Bear. The children know all the African animals used in the From Head to Toe book. After just a little prompting, all read along the repetitive lines “Can you do it? Yes I can.” We sing several songs including a dancing song that they children love. Lesley brought play dough and she and Caitlin work with the children at tables for a long time making all kinds of shapes and creatures. The children are open and willing to learn.

On the second morning, we invite the mums to the crèche for a 30 minute training on how to use books with the children. Cate demonstrates beginning the book reading by asking the children what they think the book is about and what they know about what the book is about. When reading the book she shows how to draw the children’s attention to the printed word and how to use reading conventions such as reading the title and author to start and saying “the end” together at the end of the book. The mums join in and seem to enjoy the training. Before we leave we give out about 20 books so that each cottage has some of the classic story books we brought in our luggage. (The big books stay in the crèches.)
At 11:00 the crèche ends and the children have snack and go home to play and have lunch.  In the early afternoon the school age children come home. They play all over the slides and swings and around outside. 3:00 is quiet time when all the children go to their homes so the older kids can do their school work and the younger ones can rest. The children are out again playing until 5:00 when they go to their cottages for dinner and getting ready for bed. At 7:00 the children go to bed.  
There is a great deal of work our Teachers College students can do here. Many of the language skills of these children are delayed due to medical issues resulting from HIV/Aids and from lives that until recently have been based on the need to survive. We can bring materials and especially books that can facilitate language stimulation. Our TC students can work in the crèche in the morning and then with all the children throughout the afternoons. We also went with materials into the cottages and played games that stimulate language and academic skills such as Uno, Crazy Eights, Sight Word Bingo, Rhyming word puzzles, etc. 
The Murchinson Hospital
Murchinson Hospital is the district hospital for this region and Dr. Bill Hardy is the medical director and chief of staff. Bill is on the board of Genesis and Rehoboth. We also meet Mary Reynolds, supervisor of all the SLTs, OTs, PTs, audiologists, and psychologists at the hospital. Mary is a physiotherapist who has been working at the hospital for 7 years. Several years ago the government began to require a community service year for graduates of most professional university programs. So most of the professionals working under Mary are right out of their training programs. 
We spend some time in the wards. There are essentially 3 wards—one for children with orthopedic problems, one for children who are malnourished, and two for children with other problems-often diarrhea and vomiting. Mary indicated that there were approximately 40 beds in the pediatric unit and that most of them were for children with Aids.

One boy who appears to be about 7 is very weak and thin with marks on his skin indicating that he has HIV/AIDS. He has a blank look but seems to focus his gaze on Cate so she walks to his bed. Cate asks if he wants a story and he weakly nods yes. Cate begins reading an edited version of Caps for Sale. She thinks that the pictures, which do not have the huge differences in color or representation, would not be interesting to him. After she finishes, Cate takes the book away and is ready to leave. The boy takes as big a breath as he can in and says in a weak, whispering voice, “Mmm.” Cate asks if he wants the book again and he nods, yes. This time she reads more of the book, with greater focus on the storyline. She encourages this little boy to say what she says, thinking he will just barely be able to move his hand towards his mouth, let alone call the Caps for Sale chant. To her surprise he cups his hand on the side of his mouth and repeats, “Caps for Sale, Caps for Sale, Fifty Cents a Cap.” Now this boy knows little English. His “English” repetitions consist of a bunch of vowels with a few repetitive consonants that approximate English in a similar way to how Cate approximates the Zulu language. They read the book three times. Each time he expands his participation. When the monkeys imitate the man, he raises the pitch of his voice to imitate the “Chi chi chis.” The repetitions require great effort from him—even just to take in enough breath to produce a sound.  Yet, it is obviously worth the effort so that he can to continue to participate and interact even in such a weakened state.

After a while Cate says goodbye to him and leaves to visit another ward. When Cate returns Lesley and Caitlin tell her that this boy was crying. He wants to hear the book again. Cate reads it again, and the boy joins in with the repetitions and now helps Cate turn the pages.  When the story is over, the boy begins staring at Leo O’Connor who is standing nearby. The boy, with great effort, repeats the same phrase again and again. He says this phrase louder than he has said anything before—although one still had to be very close to him to hear anything. Leo comes over to the boy and they speak in Zulu. The boy says again and again to Leo, “I want to go. I want to go.” Sadly, we cannot do anything for this boy other than what we have done. Cate asks him if he wants the book and he nods yes and Cate places it next to him in the bed. With his thin weak arm the boy reaches over, takes hold of the book, and then swings it over his body to the other side--the wall side. He reaches across as far as he can so people will have difficulty reaching in and taking the book from him. We stay a while longer, but then must to leave.

The Murchinson hospital would be a great place for our Teachers College students.  Mary and Bill suggest that we could work in the wards and the outpatient clinic. We could also provide training for the community health workers who work in the villages and who Mary says are thirsty for information. Mary and Bill emphasized the need for speech and language therapy in the schools. Currently none of the speech language therapists works in the schools and they thought we could also provide valuable training and modeling for teachers and parents.
The Genesis Program
Five years ago a man died of aids right outside the gates of the Norwegian Christian Church in Port Shepston. The pastor took this as a sign of his ministry and set in motion the work for Genesis. He saw his ministry as giving people dying with HIV/Aids the right to die with dignity. His mission then was to build a hospice for people dying of aids. It took 3 years to build the first unit. Genesis now has 3 units, a 20 bed unit for women, a 20 bed unit for men, and an administrative unit.

Although they expected Genesis to be a hospice where people would die, in fact, with the good nutrition and medical care they receive, 48 percent of the people go home. In the past year the anti retral virus (ARV) medication has been made available by the government. The world health organization recommends that ARV be given to all those with an immune level count of 300 to 350. But the South African government provides these medications only to those who have less than a 200 count. That is people who have very compromised immune systems.  

We meet one lovely woman who had contracted Aids from her husband who was unfaithful. She has a count of less than 200 and qualifies for the ARV but she also must have a support person to ensure that the all important protocol is followed. The ARV medicine is ineffective if the administration protocol is not strictly followed. So to be given ARV the patient and the support person must participate in a 3-day training about how to use the drugs. This woman does not have a support person for her. Her daughter is 14 and at a school away from her village. Her husband is not an appropriate choice. So until an appropriate support person can be found this woman, with an incredibly warm smile and heart, who looks quite healthy and even a little chubby, will stay in the hospice until she dies.  

Both units had people near death. In the men’s unit there were a number of empty beds--maybe 12 of the 20 beds were empty. When asked why, we learn that there had been a number of deaths the night before.  

One man who is very sick is being visited by an apparently much younger woman and his daughter. The man is very, very thin--skin and bones. The woman and the baby look quite healthy and robust. When the visit is over, the man picks up his daughter and walks with her into the sun and speaks with her in Zulu. Then the mother and daughter walk away and he watches until they are out of sight. Cate and Lesley wonder whether this would be the last time he would ever see his daughter and wonder if he is thinking that as well. We have learned that it can take up to 10 years for symptoms of Aids to become evident and so the future good health of the mother and baby is not certain.  

This place is very upsetting to both Lesley and Cate. While there is definitely work we could do here in swallowing and language stimulation, we agree that it would be too much for the two of us. We feel privileged have seen Genesis and to have experienced this level of deep exceptional humanitarian work.

March 19-20 University of Cape Town
Dr. Shajila Singh is the chair of the speech and hearing program at University of Cape Town. Shajila earned her masters and doctorate from Northwestern University. We know how good this program is because Liat Rabinowitz who graduated from here and then came to our masters program at Teachers College, came with excellent training. Liat helped to arrange this visit for us.

Shajila provides a great deal of information to us on the program in Cape Town and the profession in general. This program is unusual because the speech and hearing program in fully integrated into the Groote Schuur hospital in Cape Town. (That hospital is famous internationally for being the place where the first heart transplant took place in 1967.) Shajila has arranged for Celeste Samuels, one of the program’s full time clinical supervisors, to take us to visit two of their clinics.

The first clinic we visit is in one of the townships. The SLT we observe is a fourth, and final, year student. We are especially interested in seeing how they work with the many different languages and cultures of their patients from the townships. We watch two cases. The first is a woman with expressive aphasia who speaks Xhosa. The student clinician uses the woman’s husband as her interpreter. The other case is an Afrikaans-speaking colored man. This man had never received therapy. Just one month ago he saw a notice in the township about services offered for someone who stutters. He began therapy then and he and the student noted how significantly his stuttering had decreased as a result of the therapy.

Celeste then takes us to the Kangaroo Mother Care unit in Groote Schuur hospital. The SLT students show the mothers a short video on kangaroo care. This is the practice of having mothers put their babies vertically on their chests for skin-to-skin contact. According to the video Kangaroo care is more effective than incubators in increasing the baby’s weight. It developed in Bogotá, Colombia because there were not enough incubators. The mothers sit with their babies using the kangaroo care model, listen to the students and the videos, and talk.
We are amazed at the number of incubators at the hospital. We learn that the Cape Town region has more cases of fetal alcohol syndrome than any other place in the world. This is attributed to the fact that for centuries farmers paid their farm workers with bottles of wine. This so-called “dop system” was outlawed in 1980 but apparently continued until as recently as 1991. Such widespread alcoholism results in high numbers of children born with fetal alcohol syndrome which is why the hospital requires so many incubators at any one time.  

We speak with Shajila with our ideas about working and training in Rehoboth and in the Murchinson Hospital in Portshepston. She appreciates our focus on prevention and training. If we are to work in South Africa, we will need permission in the form of health certificates which Shajila can help us obtain.  

On the following day, Cate takes a tour of the townships. The level of poverty is very low in the townships. Even more disturbing is the number of people living in such poverty. Mant, many families live in miles and miles of townships around Cape Town. Similar townships exist throughout the country. The enormity of this situation underscores the great difficulty the country has in addressing the needs and effects of such widespread poverty. 
March 21-24  Thornybush Game Preserve
No trip to South Africa would be complete without a trip to see the animals. Caitlin and Cate spend three nights in Jackalberry Lodge in Thornybush Game Preserve next to Kruger National Park. We see so many animals--zebra, elephants, cheetah, lions, rhinos, wildebeests, and lots of African antelope. One day we follow a pride of 11 lions, including four males, that are hunting. Some of the lions walk within one foot of our completely open vehicle. Another day we sit in the midst of a herd of about 20 elephants. It is an extraordinary experience.

On Easter Sunday Cate looks for a traditional service in one of the local languages. After some effort she finds that Lawrence, a tracker, and David, a gardener, from the lodge are leaving after the morning drive for a service. They belong to the Zion Christian Church. The church service begins with singing and dancing outside. All the singing and dancing comes from the traditional African languages, dances, and singing styles of the local region. The multipart a capella singing is fantastic. Between songs the men do a series of rhythmic syncopated steps with high jumps all done in unison. Cate has seen enough documentaries of African tribes to recognize these dances and even the singing as indigenous to the region. 

The Zion Christian Church dress code is quite strict. Women must cover their heads, wear a skirt, and wear a jacket over their shirt. The uniform for women is a deep blue dress with a green knitted cap. The men wear dark khaki pants and jackets--all perfectly matching. they all wear a special white shoe with tire treads for soles so the worshipers do not injure their legs from all the jumping and stamping in the dancing. Both men and women wear a piece of dark blue fabric with a silver 5 pointed star pinned on it to indicate they are members of the Zion Christian Church.  

About 60 African women are in a circle singing and dancing. Within that circle are about 15 girls ages 4 to 12 doing the same singing and dancing. Cate asks the pastor for permission to join in. The pastor brings her around to the senior women--the ones who were starting the songs and the dancing. One woman leaves the circle to adjust Cate’s hat, sarong, and jacket, and then invites her in. They sing songs in Tsonga and Zulu with harmonies off all kinds -- over, under and around the melody and beat--while dancing in a circle. Cate is in heaven!
March 25-27 Johannesburg
We meet with the faculty of the speech and hearing program at Witz University in Johannesburg. The morning conference on bilingualism is, but we spend the morning in a round table discussion with Claire Penn and Heila Jordaan. We talk about the South African speech and hearing programs and compare them to those in the U.S.  Heila talks about the lack of speech language therapy positions in schools in South Africa. She is working on developing a consultative model for SLT work in the schools which, in the long run, may be much more effective than the primarily pull-out model currently in place in U.S. schools.

The following day we travel with Karin xxx, a lecturer at Witz, to the Chris Hani Baragwanath Hospital in the Soweto township. This hospital is the largest in the southern hemisphere. There are 15 speech language therapists and seven interpreters employed by the hospital. The speech language therapists are expected to meet the speech and hearing and audiological needs of the hospital. They are stretched thin because the hospital is so large.

We observe a session in the cerebral palsy clinic. Once a child is identified as having a speech or language disorder needing our services, they are given six one-hour sessions over six months--or one one-hour session a month for six months. Due to the shortage of therapists, the services are limited and primarily devoted to training the parents on how to provide services in between sessions with the therapists. They follow a transdiciplinary model so that the SLT and, in the case we observed, the OT provide services together. In observing just one session, we can see how the mother has learned to hold the child appropriately and to do the language stimulation. We note how effective this system seems to be. If the child needs AAC the mother and child will get more training. But due to the huge number of children needing services, this is the model they have in place at the hospital.
March 27. Reflections on our return home
Upon leaving South Africa we recognize how much we have learned. During our visit we saw a some extraordinary work. It is a country, and Aids is a disease, that brings out the very best in people, and also the worse. Our visit was a profoundly moving experience for all of us.

As far as bringing our Teachers College CSP students to South Africa, we found wonderful opportunities in the Portshepston area outside of Durban. Some students could provide the training and services for the children living in Rehoboth. Other students could augment the work already being done by the professionals who already provide services in Murchinson hospital, by the community service providers, and in the schools.  We were very encouraged by our conversations with Dr. Bill Harvey, Mary Reynolds, and other professionals who indicated that they would welcome our contributions.

Our work would primarily be training and modeling ways to enhance and expand the children’s speech and language skills. Due to the current and historic serious medical and nutritional needs of the children, many of them have communication delays. These delays are likely to affect the children’s academic success.  

Speech language pathologist seem well qualified to address these delays. We are trained to provide language stimulation and know the kinds of language skills that are needed to succeed academically. These include vocabulary development, broadening prior knowledge, and developing problem solving and inferencing skills. In addition, the CSP students at Teachers College come with  significant understanding of and sensitivity to cultural and linguistic differences as this information is infused throughout the curriculum. In this way, the Teachers College students will be able to integrate that information as they work with people from different cultures and who speak different languages. 

One major difference between bringing students to South Africa than to Ghana or Bolivia is the presence of speech and language therapy programs here. South African has six or seven speech language therapy programs. The quality of these programs is quite high. But, because there are not enough SLPs to provide sufficient services, the university faculty we spoke with and the professionals in the field encouraged us to come. Of course, we would ensure that we worked through the South African system to obtain whatever clearances we needed to be authorized to provide the services.  

One of the high points for us was observing the University of Cape Town clinics in the townships and Witz University’s and University of Cape Town’s work in the hospitals to learn how they work with patients who do not speak the same language as the clinician. In addition, we established potential collaborative relationships with the faculty of Witz University in Johannesburg and University of Cape Town that are likely to enrich and inform our work in the U.S.  



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