LOS MUNICIPIOS ESTABLES

When looking at the social perspective of disability, the development of rehabilitation as a special interest was considered. Internationally epidemiological factors such as World Wars I and II, war in Iran and the Polio epidemic increased the incidence and prevalence of disability and thus the awareness thereof and the need for rehabilitation (AAPMR

website, accessed 20/04/2007; University of Pennsylvania website, accessed 20/04/2007; Raissi, Vahdatpour, Ashraf & Mansouri, 2006). In SA the social aspects of rehabilitation only started to receive attention with post 1994 constitutional reform, the emergence of human rights and the equalisation of opportunities for previously disadvantaged groups which included the disabled (DoH, 2000; Unit of lawyers for Human Rights, 2000). The SA population census report on disability in 2001 (Lehohla, 2005) aimed to establish social and economic data in order to measure the impact of programmes which had been designed to address these inequalities.

Where gender and race issues have been overtly addressed following the new SA constitution (1996 website accessed 25/11/2007), disabled persons are still marginalised through lack of access to resources such as education, employment, and health due to attitudes towards the abilities of those with disabilities (Lehohla, 2005). This is in part due to disability being considered a social and health issue rather than being incorporated into all aspects of governmental legislation (Office of the Deputy President, 1997). In the WC, health services for the disabled have received attention as rehabilitation has been grouped with national priorities such as Human Immunodeficiency Virus/Acquired Immune deficiency Syndrome (HIV/AIDS) and Tuberculosis (TB).

The 2001 population census reported a disability prevalence of 5% (Lehohla, 2005). Guthrie (2001) quotes international figures of 10-12%. Guthrie attributed the low SA figure due to a lack of inclusion of certain residential facilities in the census. The prevalence may well have been higher as disability is generally perceived as a negative stigma in SA and the census relied on self reporting. Guthrie’s (2001) opinion was that global figures are reliably applicable to SA. The 2001 census acknowledged that disability is difficult to define, the definition of disability used being the lack of “full participation in life activities” (Lehohla, 2005, pp8), which was in line with the ICF. This figure also did not indicate the need of persons with disabilities to make contact with the health system which was documented as higher than that of the able bodied population (Memel, 1996; van Schrojenstein Lantman-De Valk, Metsemakers, Haveman & Crebolder, 2000; Aulagnier, Vergner, Ravaud, et al, 2005). These factors suggested that the burden of disability on the health system is thus greater that the reported prevalence.

Memel (1996) reaffirmed that disability is difficult to define and noted that the prevalence of physical disability varied between practices in the UK, ranging from 6 to 11 % where the

local estimate of disability was 5%. In SA, Gauteng had the lowest prevalence at 3.8%, the Free State the highest at 6.8% with Kwazulu Natal having the most disabled persons (470 588 persons) in absolute numbers. Although the WC was recorded with the second to lowest disability prevalence of 4.1%, the second to highest prevalence in the Eastern Cape (EC) of 5.8% (along with Northwest and Mapumalanga) was relevant as the researcher has observed frequent migration of workers from the EC to the WC. These workers often return to their families in the EC after becoming disabled and are so reflected in the census. However, the acute and initial rehabilitative interventions may well have been the responsibility of the WC where the disabling event occurred. Thus the incidence of disability in the WC could well have been higher than reflected by the relatively lower prevalence rate reported. Clinically, on discharge to the home province, systems need to be put into place over long distance to ensure maintenance of achieved rehabilitation outcomes.

The 2001 census categorised the following types of disabilities (table 2.1) for the purposes of service delivery, education, social security and employment equity. Health services are delivered to persons with disabilities according to these categories. For example emotional and intellectual disability may be dealt with by psychiatrists, sight by ophthalmologists, etc.

Table 2.1: Prevalence of types of disabilities according to the 2001 SA population census

Type of disability Prevalence of a particular disability (%) Number of affected

individuals Sight 32 721 914 Physical 30 676 794 Hearing 20 451 196 Emotional 16 360 957 Intellectual 12 270 717 Communication 7 157 918

Of the 2 255 982 disabled persons in SA in 2001, some individuals may have more than one disability and would be represented more than once in the above table.

Although age categories were given as shown in figure 2.2, the census did not specifically define paediatric, adult and geriatric populations according to health delivery services. In SA as in the UK rehabilitation services for children are generally provided by paediatric

services (Frank, 1998) but the aged are included with adult rehabilitation due to paucity of geriatric services. However the delivery of comprehensive rehabilitation is dependent on the collaboration of all state departments e.g. disabled children may receive rehabilitation services when they go to a specialised school which falls under the Department of Education and the Department of Transport is involved in organising accessibility through specialised transport services.

0

5

10

15

20

25

0-9

10-19. 20-29 30-39 40-49 50-59 60-69 70-79

80+

Age group

%

disabled persons

non disabled

total

Figure 2.2: Percentage distribution of disabled persons, non-disabled persons as well as total population by age group, according to the 2001 SA population census

The SA census showed that 60% of the total population was between the ages of 0 and 29, but disability was highest in the 40-49 year age group with a close spread over the 10- 59 year age group which has important economic implications (figure 2.2). This was in contrast to developed countries where the aged contributed largely to the disabled population (Kahtan, Inman, Haines & Holland, 1994). In these countries it was reported that at least 50% of people over the age of 75 experienced disability. The census did not provide comparative data but the shorter life expectancy of persons with disabilities in SA was evident in that only 5.1% of the disabled population was over 80 years of age and 12.8% of the general population were aged 70 and older.

The purpose of the census was to evaluate the impact of developmental programmes on socio-economic variables. Lehohla (2005) reported that disabled individuals were more

likely to have poor education and poor access to basic resources including health care. Lower employment rates as tabled below further aggravates poverty.

Table 2.2: Presence of socioeconomic factors in the disabled and general population according to the 2001 SA population census. (Figures represent the percentage of the population sample indicated living with a particular socioeconomic factor)

Disabled population General population WC disabled

population

No education 30 13 Not reported

Living in a brick house 53 56 Not reported

Access to piped water 78 85 Not reported

Available electricity 62 Not reported Not reported

Employed 19 35 25

Thus an impoverished individual with an acute illness is more likely to have inadequate medical treatment and rehabilitation and thus become disabled. Once disabled, inequalities in employment and education aggravate this poverty and further restrict access to basic resources such as housing, water and electricity. Lower educational levels can influence the capacity of an individual to manage their own or a family member’s disability increasing the risk of developing tertiary complications such as pressure sores, infection, or depression which will further perpetuate the disability (Amosun, Mutimura & Frantz, 2005).

In summary, disability was difficult to define in terms of population statistics (Amosun, Volmink & Rosin, 2005). Data regarding specific impairments was scanty and fragmented. It was the researcher’s experience that doctors come into contact with persons with various presentations of disabilities on a regular basis at all levels of health care. Doctors need to have an understanding of the conditions commonly causing disability and the socio-economic factors that impact positively or negatively on disability. With an awareness of the incidence and prevalence of disability in their practice environment and equipped with a generic approach doctors need to be able to manage any condition, as well as the multiple and complex medical, functional and social aspects associated with disability.