World Report on Disability, published on June 9, makes compelling reading for any citizen, and compulsory reading for health professionals, whose actions can moderate the effect of disabilities on people's lives.Also see:
Produced by WHO and the World Bank, the report is the first attempt to assemble best evidence about disability. The topics presented are not exhaustive, but illustrate barriers that can prevent people from realising their full potential, and provide examples that promote inclusiveness. The aim is to ease implementation of the 2006 UN Convention on the Rights of Persons with Disabilities, which established disability as a human rights issue. In presenting their findings, the authors mirror the philosophy of the International Classification of Functioning, Disability, and Health (ICF) by using a multidimensional approach that describes different domains of function, participation, and wellbeing. As the foreword by Stephen Hawking states: “disability need not be an obstacle to success”, but it is essential to provide the right environment if people with disabilities are to live productive and fulfilled lives in comfort and dignity.
Disability is shared unequally. 80% of people with disabilities live in developing countries, where the rising burden of non-communicable diseases accounts for two-thirds of disabilities. Within societies, women with disabilities are more disadvantaged than men, and those who are less economically successful have poorer outcomes than those with more income. The extent to which a person's full participation in society is limited by disability is the product of various inter-related factors. At the core is a combination of attitudes, access (physical and intellectual), education, and employment. Whereas consultation, funding, progressive policies, and decentralised services (particularly rehabilitation) could promote independence and improve outcomes for people with a disability, such actions require infrastructure and political will — in circumstances where, too often, both are lacking. The report emphasises physical, social, and attitudinal environments that enable rather than disable people with impairments. One practical example is a pavement ramp to aid people who use wheelchairs to cross a street. By embracing universal design, a concept that creates a shared solution for many users, regardless of ability, these ramps also improve access for people with children in pushchairs. The same principle of an enabling universal design should apply to the internet, which is often criticised as difficult to navigate for many people with disabilities.
Schools and workplaces are other potentially disabling environments. Not only do people with disabilities have lower participation rates in both than do their non-disabled peers; children with disabilities have lower educational attainment. Lack of agreement about what constitutes inclusion and which governmental department is responsible for children with disabilities perpetuates an unsatisfactory situation. As primary education for all is a Millennium Development Goal, surely the right of children with disabilities to receive good education (including physical education) in an inclusive setting should be a priority — and a foundation for future participation and employment within their communities.
This report reminds health professionals that people with disabilities are entitled to the highest standard of health without discrimination. Responsibilities go beyond primary prevention of disability, for instance by antenatal care, or secondary prevention after a cardiovascular event. To provide best care across the spectrum of comorbid physical and mental disabilities, health professionals need a sound understanding of access and communication needs, which should be central to all curricula.
The report makes care and policy recommendations for practitioners at all levels, as well as calling for better public understanding. However, progress on the global burden of disability will not be possible without country-specific strategies based on good research. Currently, data are fragmented and too many studies are of low quality. To provide meaningful findings that inform care and guide policy, a common framework for disability is necessary (such as the ICF), as are reliable metrics and validated instruments. This approach will require leadership from a well-supported, innovative cadre of researchers trained in many methodologies, who can focus on practical questions of direct importance to people with disabilities and other stakeholders.
For The Lancet themed issue on disability see www.thelancet.com/themed-disability.
Disability: beyond the medical model