About a year from now, in 2024, the first cohort of students enrolled in the Master of Occupational Therapy program at the University of Antananarivo, Madagascar, will graduate. And they will be the first in their country to earn the degree.
These graduates represent a decade-long effort to raise, train, and employ 100 occupational therapists in a country that had only one, a foreigner, in 2011. The country has long been desperate for the kind of expertise and service professionals in this field can offer, and the work of one therapist in particular, Anri-Louise Oosthuizen, is paying off.
Madagascar is home to 27 million people, almost half of whom are under the age of 18. Located 250 miles off the coast of East Africa, it is one of the largest island countries in the world. Despite its natural beauty and resources, Madagascar is consistently listed among the top 10 poorest countries in the world, and poverty affects 92 percent of the population. The country also ranks as one of the worst in terms of chronic malnutrition, and nearly half of children under the age of five experience stunted growth. According to Wateraid, 12 million people in the country do not have access to clean water, and worm and parasite infestations are common and often severe. According to the World Health Organization, up to 15 percent of the population of Madagascar — about four million people — suffer from disabilities.
The practice of occupational therapy helps people overcome many of the barriers these kinds of physical disabilities cause, allowing them to better perform everyday tasks and live more independently. The initiative to send occupational therapists into every corner of Madagascar was an effort of Madagascar’s Ministry of Public Health, a vice dean of the University of Antananarivo, and Oosthuizen, a certified occupational therapist from South Africa who began her work in Madagascar as a missionary in 2009.
When she was 12, Oosthuizen recalls, she read about teenagers who lost limbs in a boating accident and could not stop thinking about them.
“I wondered, how would these kids be able to eat? To wash themselves? To walk to where they needed to go? To write school homework?” she said in an interview with Common Good. “I really was overcome by the concern of how they’d be able to manage everyday tasks and what the quality of their lives would be as a result of the accident.”
By the time she enrolled at the University of Stellenbosch years later, Oosthuizen knew she wanted to be an occupational therapist. “I think it’s the most beautiful of professions,” she says. “It helps people do the activities they want to do, have to do, and are expected to do.”
However, she says, “If your goal is to be the hero in the story, what you do is not going to be helpful or sustainable.”
“I wanted to work as an OT in Madagascar, but there was no such outlet, since there were no OTs there. There was no real frame of reference for the skill. I knew some Christian missionaries serving in the country from my home church in South Africa, and they told me that teaching children English, for instance, would be easier than practicing OT.”
She arrived in 2009. “It was a complete culture shock,” she recalls. “The stark poverty, the hunger, the masses of homeless people in the capital, the lacking infrastructure, the disorganization and chaos that appeared to be in every street from my life in South Africa. And the Madagascar culture was just so different from anything I’d ever known. I just couldn’t wrap my head around it.”
Oosthuizen began work as a third-grade teacher at an English-speaking school, but existing health issues of her own were persistent, and she lacked the health care resources that had been available to her in South Africa. “It was a tough first two years, with both my health and the cultural challenges,” she recounts.
But these challenges prompted her to begin working as an occupational therapist despite the country’s lack of its own educated or employed occupational therapists. The need was clearly dire. And urgent. “This was, in fact, what God wanted me to do here,” she says.
She approached the Madagascar Ministry of Public Health in 2011, who at the time was just beginning to explore the need. With that momentum, in 2014, she created a nonprofit organization, Growing the Nations Therapy Programmes, to make the services more widely available: “Our first phase was raising awareness, then establishing an educational program and national association to train and then create employment opportunities for newly qualified therapists.”
Oosthuizen knew she had to ensure the new program was Malagasy-owned and Malagasy-driven, but internationally recognized. So she approached the University of Antananarivo about creating a program, and Oosthuizen created a curriculum grounded in the Malagasy culture.
“The local Malagasy culture,” Oosthuizen says, “is one where questions are not typically asked. For instance, children are not encouraged to ask questions of superiors — it’s hierarchical. OT students needed to learn clinical reasoning, a crucial skill of the profession, and to be bold enough to ask questions and exercise this reasoning in one-on-one services to patients. The curriculum had to find that appropriate balance of questioning and reasoning within the Malagasy culture to practice OT effectively.”
She explains further, “We didn’t want to base our program on Western curriculum because human activity — the central component of occupational therapy — is contextual and cultural in many ways.”
She hadn’t left teaching altogether after all.
Local support comes through
A local church became an integral piece in the program development. Tana City Church, led by Pastor Tanteraka Randrianjoary, allowed workshops, clinics, and special events to take place in the church’s space and was a source of material and spiritual support for the work. The church even offered assistance in translation by Tanteraka’s wife, Jaela, who is fluent in French, English, and local dialects. She translated the courses to students, some of whom were part of Tana City Church’s own congregation.
Through a partnership with Redeemer Presbyterian Church in New York City Tana City Church received teams of American occupational therapists and short-term medical teams that could provide additional academic resources and continued professional training for health-care workers, which supplemented the work of Growing the Nations.
The curriculum was soon approved and recognized by the World Federation of Occupational Therapists, the global board governing the integrity of the profession worldwide. The first crop of students — taught by Oosthuizen herself — received their bachelors degrees in 2018. The government of Madagascar employed its first therapists in 2020, and registered occupational therapists now work in a number of key cities across the country. “There was immediate buy-in,” Oosthuizen says.
Every year since 2018, 13 to 16 new therapists graduate from the University of Antananarivo’s occupational therapy program. It’s an opportunity for an improvement in the quality of life for the country, for that 15 percent of disability sufferers and more, not just a few of its citizens.
Public health is public safety
“Living with a disability is a tremendous extra burden on a family,” Oosthuizen says. “It impacts all aspects of family life: finances, physical energy, house layout, time, resources. Rehabilitation aims at healing and restoring what has been lost.” But access has also helped combat some culturally accepted assumptions about those who experience them.
“One of my saddest memories is attending the funeral of a disabled child. The family would not bury him in the family grave,” Oosthuizen explains. “So many believed disability was a curse.”
When it comes to health care in Madagascar, illness is treated primarily through four means: cultural beliefs, cultural healers (some of whom focus on more herbal remedies while others focus on spiritual approaches), massage (sometimes even on broken limbs), and modern medicine. A health-care provider may consider some or, quite commonly, all of these approaches.
Still, accessing any health-care provider can be difficult as there is a nationwide shortage of doctors: In 2010 it was reported that Madagascar had an average of three hospital beds per 10,000 people. It is not surprising that in 2009, adult life expectancy in Madagascar was 63 years for men and 67 years for women.
“The curse is no longer,” Oosthuizen says, reflecting on the years’ developments in access and education. “People are showing greater compassion for people with disabilities, and they’re increasingly being treated with the respect and dignity they deserve.”
A life’s work, full circle
The Madagascar branch of Growing the Nations is now transitioning out of Oosthuizen’s hands into those of the Malagasy employees that have been working with her and the organization since the beginning, and so her work has come full-circle. Although she feels wistful about stepping away from heading up something she’s poured so much of herself into, she feels confident and optimistic her work will carry on through the new directors.
“I can’t tell you how much hope I have for the country,” Oosthuizen says with optimism. “It’s all in God’s hands. Everything is. I’m just so blessed, and I can’t wait to see what the future will bring.”
As Growing the Nations’ slogan states, “One life is worth it all.”