Sunday, 28 March 2010

Feldshers, barefoot conductors, super-conductors... or what?

Any other solutions to a very big problem?

Feldsherism

The question of 'feldsherism' has been intermittently one of the hottest questions in medical professionalism for well over a hundred years.

It refers to the independent medical practice of people with training that is different to or less than (the two are not necessarily interchangeable) fully trained medical;l practitioners ('doctors'). The term 'feldsher' is originally Russian (фельдшер, from the German Feldscher) but the question has arisen in different guises in different countries.

In the United Kingdom the recent discussion has been around 'nurse practitioners'. In Hungary midwives are presently a hot issue (one long resolved in the UK).

And the really big social-policy manifestation in my lifetime has been the Chinese 'barefoot doctor'.

To my lay understanding certain features are common (though not universal) in situations where a feldsherist solutionor something like it  is advocated or adopted. I know that feldsherism has been subject to considerable scholarly enquiry over the years but I have no time to dig into this. The following summary points will have to suffice, however, for present purposes.
  • A situation where there is widespread medical need and a massive shortage of doctors (the original term comes from the German word for for 'field surgeon'). This is fundamental to feldsherism in the modern world. Somebody has to help, or nobody will. There are few or no doctors.. There would be no possibility of fancy medicine even if there were. All the same, rough-and-ready, applicable to particular situations, may still prove a life-saver or a major ameliorator of human suffering.
  • There are major non-military applications of this too, of course. At then present day he developing nations spring at once to mind. The nineteenth and twentieth centuries presented examples aplenty in places that are now economically well developed.
  • If you wait till there are 'enough doctors' trained (whatever 'enough doctors' means) you will wait too long for the next generation or two to benefit, and perhaps you will wait for ever. Where that is recognised as politically, humanly or morally unacceptable, then something has to be done.
  • 'Modern, scientific medicine' might be wonderful but there are other, traditional approached to care and healing, indigenous to the place and perhaps ready and waiting for fast uptake. And cheap. So, incorporate them.
  • Provide a stripped-down, shorter professional training, with lower educational requirements for entrants to training, a a focus upon treatment for a range of circumscribed but very common conditions, and then a below-degree-level qualification. This does not necessarily mean  abandonment of the concept of standards. Just different ones. Horses for courses.
  • Expect many or most of the practitioners for this new (lower-paid, lower-status) profession to be women.
  • Watch out for a major reaction from some (though not all) established medical practitioners.
Perhaps I am presenting a caricature here, based upon ignorance. If you are reading these words, check on this. Form your own undersatanding

Conductive felsherism?

I do so because the present situation in Conductive Education is rather like that of the first couple of points proposed above. For 'doctors' read 'conductors:
  • A situation where there is widespread habilitational, rehabilitational and special-educational need and a massive shortage of conductors This situation is fundamental to feldsherism in the modern conductive world. Somebody has to help, or nobody will. There are few or no conductors. There would be no possibility of fancy Conductive Education even if there were. All the same, rough-and-ready, applicable to particular situations, may still prove a major ameliorator of human suffering.
  • At the present day the developing nations spring first to mind. But even in places that are now economically well developed is the situation for most people who could potentially benefit so much better? Be honest. The availability of Conductive Education for all is about as socially devisive in the wealthy nations as just about anything that you could think of.
As for training, it should be clear to everyone that potential demand is so vastly ahead of potential production that Conductive Education faces a problem here that is, simply speaking, insoluble. :Let us have no comforting, namby-pamby talk about 'challenges;' On present analyses, we face an task that is impossible. This leads to the next two features of feldsherism as outlined above. Again, there is quite a good fit with CE today and in the foreseeable future:
  • If you wait till there are 'enough conductors' trained (whatever 'enough conductors' means) you will wait too long for the next generation or two to benefit, and perhaps you will wait for ever. Where that is recognised as politically, humanly or morally unacceptable, then something has to be done. Here the analogy of course breaks down. There is no political, human or moral force in society for a way to rescue disabled children and adults, and their families, from a culture that implicitly accepts pedagogic neglect (however well meaning and benign) as being somehow in accord with the laws of nature pedagogic Without that force for change then you will be waiting for ever.
  • 'Modern, scientific medicine' might be wonderful but there are other, traditional approached to care and healing, indigenous to the place and perhaps ready and waiting for fast uptake. So, incorporate them. Perhaps a little more serious attention to the historical and philosophical roots of conductive pedagogy might be instructive. Just what sort of doctor was András Pető anyway, and what did he bring to the party to ameliorate the lot of the disabled (and. let us not forget, people with all sorts of other conditions) in the desperate days of post-War, early-Communist Hungary? Think on't. If you want a steer on this, I would advocate (yet again) looking at András Pető's two published works on the nature of healing. And what about traditional approaches as candidates for incorporation today? Look no further than the burgeoning CE research literature, from China.
And what sort of professionalism might this imply for what is presently called Conductive Education? . The last two points on medical feldsherism proposed above night be indicative:
  • Expect many or most of the practitioners for this new (lower-paid, lower-status) profession to be women. To report that this is already the case amongst existing conductors is not to condone the situation, merely to acknowledge it. Depending upon the society that one is considering. this situation may be or may not be open to change.
  • Watch out for a major reaction from some (though not all) established conductors. You might think that doctors might consider themselves professionally secure. Medical reaction to felsherism could suggest otherwise. Conductors are nothing like as securely established as are doctors, just about hanging on in fact, and may find the very thought of conductive feldsherism threatening not just to their status but to their very livelihoods
But is 'a conductor' as presently construed and defined (and I should love to see that in black and white from some brave soul or institution) really an a priori solution to the tasks that the even the present generation of relatively well healed and fortunate first-world users of Conductive Education would like to see solved? And how useful is this model of professional training and delivery to everybody else?

Other ways?

Feldsherism is but one alternative approach:
  • Most obvious is recourse to training existing professionals, in something (usually the so-called and diversionary 'principles of Conductive Education'). This has still to be properly argued out and even, where it has been tried, it has still yet to be properly described . (As ever, for those who favour the concept of a 'challenge', please prove me wrong by directing us to the literature that does just that). The actual problems here would seen immense, not least the oil-and-water problems at both the philosophical and the practical levels, and the sheer logistical issue that the existing professionals may be as hard to come by as conductors, and cost even more!. Minute advantages, maybe, in some yet to be described circumstances, but no solution at a molar level.
  • Less obvious – and far more radical – is Karóly Ákos's proposal to deinstitutionalise Conductive Education and go instead direct to the basic cell of human society, the family. As he put it in the epigraph to the book Dina, quoting Goethe's Faust: 'There is a way… the mothers!' Of course this has been tried. In the late nineteen sixties, when Karóly Ákos was actively involved with the then State Institute in Budapest, parent-and-child work appeared as the a fundamentally new way of working. Ad hoc variations of this have appeared since, in different parts of the world, but no formulated extension or elaboration into, say, other age groups. And certainly, despite the ever-extending possibilities that arise from the Internet, no attempt to update the epistolary practice recorded in Dina itself into the world of the Internet.
  • Less obvious and as yet to be explicitly mapped out, never mind tried out in practice is some sort of 'super-conductor', with a vastly extended and more broadly applicable knowledge base – and with a social role much different from the conductor of today. This could of course be developed out of the existing workforce, a situation that would doubtless be welcomed by many conductors. Or it could by-pass it altogether, which might be rather less acceptable! The important first step in elaborating such a possibility, though, is not surely neither acceptability nor job-enhancement, but an a priori examination of the world might require. More radical proposals such as adumbrated in the previous point, may have to await the arrival of superconductors.
There is something else, another way to extend a limited trained :workforce with something cheaper and quicker to bring into production. This is common already in teaching, nursing and the therapies: 'assistants'. But the very term gives the game away. Autonomous practice is not implied. Nor is a discernible knowledge base in its own right. This is not what is being implied here by 'conductive feldshers'.

So what might a conductive feldsher be?

Who knows? I have been carrying this notion about for years and years, and talking with people about it, but I think that this is the first time, that I have committed it, however informally, to paper. It is easier to do so now than it was even just a few years ago, as the degree of the crisis ahead of Conductive Education begins to sink in.

There is no empirical answer yet to this question – not yet at least in the public domain. But there are certainly potentially communicable experiences that might contribute to understanding the possibilities. The work at Sizanani Village in South Africa is an obvious example.

And of all places, China seems an obvious place to start thinking of 'barefoot conductors'.

Perhaps they already exist.

5 comments:

  1. Dear 'V' and 'Anna',

    Your information and comments are important and interesting. I have therefore given them a posting of their own:

    'Aids, assistants and students',

    http://www.conductive-world.info/2010/03/aids-assistants-and-students.html

    I do hope that you and others will continue this discussion there.

    Meanwhile, I also hope that others will comment here upon the central issues raised in the posting above.

    Andrew.

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  2. Andrew,
    my original querie was--after I read your blog and made a connection with the "feltshers" you mentioned to the "aids" that I read about on www. peto.hu--that the two are indeed could be connected or no. I was just wondering, which one can who doesn't hold the full future job description of the aids who are about to be trained.
    I think my querie was misunderstood (implying that I meant that the trainee conductors' sole purpose is to perform as aids, which is neither the case nor was I implying it). It's okay, such things happen, but I still have the original question.
    To me it seems very likely that the aids will flee the minute they hold their qualifications which they will obtain in 2 years, so there we have the feltchers you were talking about. This hypothesis may be true or false, I don't know.
    Vikki

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  3. Feldscher-conductors

    Field doctors actually saved the lives of a lot of people, even though they possibly failed to save a lot of other lives that a qualified doctor would have saved.

    I suppose that you could say the same of feldscher-conductors: they would probably be better for the clients than no conductor, but they would perhaps not reach the same wide client base that a conductor can.

    As I have often thought about the way that China will progress, I was not surprised when I read at the bottom of this posting that it was one of the places being thought about here.

    In a country like China feldscher-conductors are probably the only way ahead. It would not work with “conductive assistants” unless they also had a pedagogic background. Without this, they might be expecting, and expected, to take on more of a caring rather than a teaching role.

    However much one might disapprove of other professions with an extra bit of conductive training, I would still rather work in a conductive group with a teacher with such an extra conductive pedagogy qualification than with assistants with no pedagogic qualifications who I have to train up on the job.

    I can imagine that feldscher-conductors could work in China just like the feldschers, the PTKs in Germany. China will have teachers and perhaps social pedagogues who have taken a course in conductive pedagogy and then they are bound to have extra people to do the towel-folding and the plinth-moving just as the field-doctors would have had too.

    Towel-folding is not the role of a conductor – or of an assistant. It is something like cleaning a toilet, something that every individual does because it is part of life. If there is a cleaner present then the cleaner does it. If none of these do it then the person who sees the job needs doing, does it, whoever they are, whatever the qualification they have!

    I guess that China will do what Germany has done, give extra training to other professions, but it will on a much bigger scale.

    But I doubt that such Chinese feldshers will be working alongside conductors as usually happens here, but working alone which is why a conductor’s aid is not what they need there. In the many centres in a country as huge as China, they won't have any “conductor-conductors” to aid - never mind “enough".

    I often consider whether the way China is doing is possibly the ideal way. They have started off as a country with official organisations wanting to establish provision of conductive education for its clients. They have not begun as a lone parent or professional wanting to convince the government that conductive education is something that they need, as is the case in many other countries. China have gone about finding a way to supply it, and to supply conductive education to as many of the population who need it as possible. They have no other way than to go “feldscher”.

    I wonder whether this way, using Chinese pedagogues with an extra conductive training, could possibly work better than where “conductor-conductors” work in some other countries and are expected to provide something other than what they were trained to do. “Therapy” for example.

    Most other countries are still struggling to get official organisations to accept conductive pedagogy as a part of the education and rehabilitation systems, China has the struggle of training those who will provide it. These will be feldscher-conductors, not conductor’s assistants as there are few or no conductors for them to “assist”!

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  4. So...
    "Towel-folding is not the role of a conductor – or of an assistant. It is something like cleaning a toilet, something that every individual does because it is part of life. If there is a cleaner present then the cleaner does it. If none of these do it then the person who sees the job needs doing, does it, whoever they are, whatever the qualification they have!"
    So, if that "whoever" is the trainee conductor, or the conductor, do carrying out such things "degrade" them?
    When I said that trainee conductors and conductors do such thigs, which is EXACTLY THE SAME that you're now saying, I was accused of degrading the (trainee) conductor. Now it turns out that conductors do indeed do such jobs when there's nobody else doing it. So what was wrong about what I said in the first place?
    I remember folding towels as a trainee conductor. Was that wrong? Please enlighten me, because now I'm in the dark: As a result of occasionally folding towels, I most probably failed to learn my profession, because it degraded me? Or is folding towels something that "every individual does", and it doesn't degrade them? Which one, then?
    Are we arguing here for the sake of argument? If we do so, I see no point.

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  5. Hi Andrew,

    I feel I should leave a comment as I believe a work with a small but excellent group of conductor fledschers. As you know I work in Brazil and have for the last two years been "on my own" as a lone conductor of a project here. There are no brazilian conductors in the world so when this project began it had to hire conductors from other countries and "bring" them in. With a small group established here I cannot carry out my work alone, and not being able to afford other conductors we opted to hire brazilians to carry out the work of what in some countries we would call assistants or aides.

    The people who work alongside me each day are called educadoras (educators). This is a name we (the project) decided to give to them. They are all professionals in their own right, some are teachers, some physiotherapists, we have had occupational therapists and speech and language therapists amongst others. They are all fully qualified but when they enter the classroom they do not practice the work for which they are qualified, they practice conductive education.

    I am the conductor, I design the routine and the programmes, I am responsible for all planning, reports and correspondence with the parents, I lead all the programmes and am responsible for training the educadoras. So what do they do? The educadoras work directly with the children facilitating as they have been taught to, and do so to a high standard. They are not conductors and probably never will be unless conductor training is introduced within brazil. But their work as educadoras is very highly respected by all, including a number of conductors who have had the opportunity to see them work. They understand how CE works, they embrace the method and they are excellent at their work, which also is my work. We are a small group, and we have different job titles but we are all equal, we all carry out the same work with the children, we all have ideas which we share, we all have responsibilities which we also share.

    For us and our project it works, maybe it wouldn't work in another country, but it does for us.

    Becky Featherstone

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