Speech Therapy at United Nations

Address given on speech therapy at United Nations, Cambodian government meeting

Jul 13, 2015

Thank you for the opportunity to talk to you. Today, I will talk about the biggest gap in basic services for people with disabilities in Cambodia. Something that affects one in 25 people, where there is virtually no support for it. I will explain why this is a problem, what we at OIC so far have done about it,  and what our plan is for the future. I will detail why this is an urgent issue that needs to be addressed, and ask for your support in addressing it.

I was born in Australia, a country where health and education services are still excellent, where the system supports even the most vulnerable people. I trained as a physiotherapist and worked in the public health system for a number of years, before deciding to go overseas and volunteer in Vietnam and India. I studied development studies while working in the field of disability in Australia, and took up a posting with Handicap International in China in 2011. I came to Cambodia 3 years ago to work with CABDICO, a local Cambodian organisation who mostly work in Siem Reap.

CABDICO is a small organisation that sends staff out to the villages outside Siem Reap town, to provide Community Based Rehabilitation to children with disabilities. These people often spend hours riding motorbikes on dusty roads, through villages where there are no hospitals or health centres, to see children with all kinds of disabilities. CABDICO staff have been trained in physiotherapy, and have knowledge in basic health care, social work and special education. They are proficient in working with children with physical disabilities.

At the end of my first year working with them, one of CABDICO’s staff members, Phearom, told me that 70% of the children they saw needed speech therapy, and yet, none of them had the skills to provide it. This surprised me, because having worked as a physiotherapist in Australia, I couldn’t imagine what it would be like to treat people without the basic knowledge to do my job.

One of the children that needed speech therapy was Ouk Ling, a boy I met when he was 10 years old. Ling has cerebral palsy, a disability that occurs because of brain damage around the time of birth. Ling has an obvious physical disability, he could walk but not run, but Phearom was able to help him improve his mobility through physiotherapy. However, Ling also had a problem with speech. His speech was slurred to the point where people assumed he was stupid. But Ling isn’t stupid, he just couldn’t speak clearly.

We gave Phearom basic training in speech therapy and she slowly applied these skills to Ling. She worked hard getting his family to practice with him, and bit by bit, his speech started to improve. Phearom also gathered Ling’s teachers together so they could understand his condition better. After only a few months, Ling went to school for the first time, at the age of 12. But he’s not only participating, he’s excelling. Ling is coming 2nd in his class.

Ling’s story teaches us the value of speech therapy, and how, even with very little resources and time, we can change lives dramatically.

When we talk about speech therapy, we’re talking about two different populations. Those who have problems with communication, and those who have problems with swallowing.

For communication, think of a child like Srey Ran, who has Down Syndrome. Communication is two way, and although Srey Ran can talk, her ability to process incoming communication is different to other children her age. For those who are around her, they need to adjust their behaviour to suit this.

For swallowing, a child like Visal, who contracted an infection after falling into a septic tank. He cannot swallow food or liquid safely like you or I.  Food and liquid will often go into the lungs, and he’s at risk of contracting pneumonia and then dying. In fact this population is 13 times more likely to die young as a result. In Cambodia, tens of thousands of people are dying unnecessarily due to lack of speech therapy.

In 2012, Handicap International’s country wide study on disability found that the 4 most common disabilities amongst children are all non physical: hearing, cognition, speech motor and speech language. And yet, much like Phearom at CABDICO, most people who work in the disability sector have skills that are appropriate only for physical disabilities. The time is now for Cambodia to recognise this issue and take steps to address it.

We estimate that one in 25 people in Cambodia need speech therapy. In other words, 600,000 people have a problem with communication and swallowing. This number is consistent with other countries, so the disabilities themselves aren’t the problem. The problem is the lack of services to support this group.

Despite this, there is no university course in speech therapy, no Cambodian university-trained speech therapists, and very little awareness of the need throughout the country. There have been fly in fly out trainings conducted in Cambodia, and although these training sessions have helped NGOs with performing speech therapy, they haven’t help build Cambodia’s ability to provide speech therapy for itself.

In 2014, we started the first independently evaluated pilot program in speech therapy.  Our aim was to investigate whether there was a model of speech therapy training that could work in Cambodia.  Over 3 two-week modules, we trained 19 community workers in speech therapy, who then reached over 100 children who needed it.

An independent evaluation of our pilot program, the results of which are in front of you, validated the work we piloted.  Not only is the need for speech therapy validated, but also the model that can address this need.

Given the small budget we had to work with, and given the lack of human resources, there were a number of key successes worth highlighting. The percentage of children who improved communication with their families increased from 21% to 84%. Three out of 13 children went to school for the first time because of speech therapy. Nine out of 13 children improved their ability to swallow. These are by no means small achievements, they indicate the potential for speech therapy to provide meaningful change to lives of people in Cambodia.

Of course, the evaluation was not all positive. There were some recommendations, based upon the limitations that the pilot had. Firstly, we were unable to do awareness raising within the communities we worked in, and this was a significant barrier to acceptance of therapy. Monitoring and evaluation of the pilot was insufficient. Just as people in Cambodia have worked hard to develop a common sign language for Khmer, so to do we need a joint effort to develop common language in speech therapy. All of these recommendations require a coordinated approach, with commitment, resources and action.

I want to pause for a moment and explain why awareness raising is so important. A good example of how a new service can suffer from a lack of awareness is physiotherapy. A few months ago, I talked to a young Cambodian physiotherapist. He told me that he was going back to study medicine because he worked in a system where the doctors don’t understand what physiotherapy was, and because doctors were still decision makers, he couldn’t do his job properly. He wanted to study medicine to become a decision maker. In a country with less than 200 physiotherapists, we can’t afford to have them working in other professions. This conversation taught me that having a university course is not enough. People within the health system, and within the wider community, need to understand what the therapy is, or else, it is ineffective.

From here, we will continue to run training programs in speech therapy, to have immediate impact. We will train three groups. Firstly, health professionals such as doctors, nurses and physiotherapists. People who already see those who need speech therapy. Secondly, teachers, to raise their awareness to accept children with these needs into the classroom better. Lastly, we will train government officials to raise their awareness of the need for speech therapy, to start to create policy around speech therapy and send health professionals for training.

We will also establish the first university course in speech therapy in Cambodia, by the year 2020.  All of this will help us to realise our vision of universally accessible, locally led speech therapy. It’s worth pausing for a moment to think about the meaning of these words. Universally accessible: everybody who needs it can receive it. Locally led: led by the Cambodian government.

Now why should the Cambodian government amongst the many other things that need addressing, prioritise speech therapy? I think it boils down to 3 points: participation, economic growth and unnecessary death. By sheer numbers alone, 600,000 people are not participating in their communities because they cannot access speech therapy. Children cannot access schools, adults cannot get jobs. Economic growth: By comparing the cost of treatment with the productivity that these people could bring to the workforce, countries lose approximately 3% of their Gross National Product ever year they wait provide speech therapy. In Cambodia, this accounts for $400 million in lost income every year. Life and death: Although it is hard to estimate, tens of thousands of people are dying because they cannot swallow food and liquid safely, either through pneumonias or through malnutrition.

We know that we cannot do this alone. OIC started as one person for the first year, then two, then now we have 4 staff and 18 volunteers regularly working with us. But we need the cooperation of local and international NGOs, the UN, and government at all levels.

There are three ways in which I see this cooperation happening:

* We want to set up a task force to address this issue, comprising of NGO representatives, but also of government and private sector people who want to develop speech therapy.

* We want to train government staff in basic awareness around speech therapy, and this will require MOUs being fast tracked within the Ministry of Health. We also want the approval for firstly a short course, then a post graduate, and ultimately an undergraduate degree in speech therapy at a local university. From the Ministry of Education, we want approval to include speech therapy into the other inclusive education efforts that are currently happening.

* In the area of awareness raising, we want to hold an event with government, NGO and university partners to raise awareness of the need for speech therapy in Cambodia, and let people know that there are alternatives. We want key government leaders to become ambassadors of our work, to throw their support behind this cause.

Together, coordinated action will lead to a new generation of Cambodian speech therapists, equipped to deal with the one in 25 people who need them. But also, it will lead to the inclusion of a new generation of children growing up, who have been the most under-represented and vulnerable until now.

I will finish with a quote from someone who knows what she is talking about. ““I think speech and communication is not just changing the children but changing the communication behaviour, to start to connect to each other, to make society have bravery, to know how to communicate, to love each other, yes, it’s very good… speech therapy should have come here longer ago… It should have come here six or seven years ago when I first started to work… Why has it just arrived now?”

These words were spoken by Phearom, who could be one of the first generation of Cambodian speech therapists. Thank you.