• Nick

Disability. Where do we draw the line? part one.

I quite clearly remember discussing the concept of social welfare and universal healthcare during my seventh year of schooling, in what was a socially progressive school’s offering for the subject called Human Society and its Environment. Being thirteen years of age at the time, it seemed to me given that everybody is entitled to access healthcare, and all people with disabilities should be entitled to the same things that I should be. I still feel the same way to a degree, that is it pulls at my sympathy to think that someone who was born with some physical or mental impairment is subject to the slings and arrows of that pathology. I have been lucky enough to be born without serious affliction, and the maladies I have suffered in my life so far have either been temporary or caused by my actions (sporting injuries). I was also lucky enough to be born into a family with sufficient means to allow me the best treatment and recovery for injury and sickness that I have suffered.

What I hope to do in these pieces is open a discussion that I perceive has not been had nearly enough of late, and that is asking where do we draw the line with respect to disability. I have intentionally phrased the question to be somewhat ambiguous, and will discuss the different segments in further detail below. I invite questions and comments on this and have written this piece without a preconceived idea other than the fact that I don’t think this is being talked about enough.

What constitutes a disability?

The United States’ Centers for Disease Control and Prevention (CDC) defines a disability as:

“any condition of the body or mind (impairment) that makes it more difficult for the person with the condition to do certain activities (activity limitation) and interact with the world around them (participation restrictions)”

Upon reading this definition, I immediately found it to be very broad. Under that definition, my most recent injury which was a fairly nasty muscle tear, would be classified as a disability. The injury took around six weeks to substantially recover and was reasonably debilitating as to being ambulatory in the normal course of daily life. I was hobbling for quite a lengthy period of time, was sleep deprived due to the nature of the injury and was in a fairly substantial amount of pain. Not taking into account the forementioned definition, I did not consider myself to be disabled (far from it). My wife and family provided me some immediate care and sympathy, however, this dried up after the first few days after the injury occurred and I was overall expected to get on with my normal life.

To contrast this, I sought to find out some of the historical definitions of disability. There was no better place to look that A History of Disability (by Henri-Jacques Stiker, David Mitchell and Sharon Snyder). The earliest possible definitions found of disability under this come from religious texts which talk of specific diseases or injuries which acted to lower ones social and religious standing. These diseases and injuries include lameness, loss of limb, skeletal deformation, humped back, blindness etc. One can see that that the earlier concepts of disability were significantly more acute and precise when contrasting it against the current one of the CDC. Is this difference in definition a problem? Not necessarily, and it should be remembered that thousands of years ago modern medicine wasn’t around so firstly diseases that can be specifically diagnosed now could not be and secondly the mortality for many afflictions would have been so great that a person born with a great enough debilitation would not have been able to reach adulthood. In any case perhaps this is a classic example of Dr Nick Haslam’s Concept Creep.

At what point does an affliction become a disability? Or should there be subcategories such as: significant, insignificant, temporary, long-term, permanent etc. To get specific, we will look at Australia’s National Disability Insurance Scheme Act 2013 (the Act) which gives rise to the National Disability Insurance Scheme (NDIS) which for the point of simplicity is Australia’s main welfare system with respect to disability. The Act at section 24 sets out the requirements for a person to be considered disabled under the NDIS, and has the following requirements (summarised by me):

a) the person has a disability that is intellectual, cognitive, neurological, sensory or physical impairments or to a psychiatric condition; and b) the disability is likely to be permanent; and c) the disability reduces function in communication, social interaction, learning, mobility, self‑care, self‑management; and d) the impairment or impairments affect the person’s capacity for social or economic participation; and e) the person is likely to require support under the NDIS for their lifetime.

I have used the word in bold to highlight that in order to meet the disability requirements a person must suffice each element of the above. It is interesting that the Act does not feature a definition of the word disability its self, presumably to avert the risk of leaving a person in need of the NDIS without the ability to obtain its funding. Contrasting this type of open style of requirement against something like the Medicare Scheme (which is Australia’s social welfare system for healthcare), there is a schedule of existing treatments which a medical provider may access directly from the Medicare rather than getting directly from the patient (or vice versa). There are numerous common services that are not available under the Medicare Scheme (off the top of my head, Magnetic Resonance Imaging scans ordered by a general practitioner, physiotherapy, significant amounts of dentistry) so having a definitive list of disabilities would not be breaking ground. I realise that the Medicare Schedule is closer to the NDIS Services, however, the point I am trying to make is that definitively codifying medical practises or diseases is not virgin territory.

How prevalent are disabilities?

Looking at the Australian Bureau of Statistics (ABS) the following are some interesting statistics:

  • in 2018, 17.7% of the population had a disability (down slightly from 2015);

  • in 2018, 5.7% of all Australians had a profound or severe disability;

  • in 2018 there were 205,200 Australians with autism, a 25.1% increase from the 164,000 with the condition in 2015;

  • From 2003 to 2018 there was a ~10% increase in the prevalence of disability.

The ABS uses the following definition for disability, which again is significantly different from the Act “any limitation, restriction or impairment which restricts everyday activities and has lasted, or is likely to last, for at least six month”. Comparing this to the CDC statistics (keep in mind their particularly broad definition), it appears the prevalence of disability in the United States is ~21-22%. The main difference between the definition from the CDC and the ABS is the element of time. The Australian counterpart requires that the disease (we wont even broach their use of nouns to describe this) must last or be likely to last for six months, whereas the US counterpart does not require any amount of time. It is isn’t hugely surprising that the US prevalence of disability is significantly higher.

To give this further context, it is useful to consider the prevalence of disability in a world far apart from the US and Australia. In 2011 Twenty-year trends in the prevalence of disability in China published data looking at the prevalence of disability in China. In short it found the weighted prevalence of disability was 4.9% in 1987 and 6.5% in 2006. This is around a third of the prevalence in Australia, and around a quarter of the prevalence in the US. That is a pretty substantial difference. Notably, the 1987 component of the Chinese study used the World Health Organisation’s (WHO) definition of Impairment which was:

in the context of health experience, an impairment is any loss or abnormality of psychological, physiological or anatomical structure or function” which also included a characterisation of the same to include “loss or abnormalities that may be temporary or permanent'’.

Contrasting the WHO definition against the ABS, CDC and the Act, it appears they are all sufficiently similar. The WHO definition went on to characterise various subsets of impairment, however, non-definitively. They all require that there is a loss, diminution of function, abnormality, or impairment to health and/or participation in normal life. The Act requires that a disability must be permanent or thereabouts, however, the WHO’s definition didn’t require this, so what is the source of the large disparity?

Chinese disability welfare system

I have to start of this section to state that I am no expert in Chinese law or their welfare system. I invite anybody better versed and with a more thorough explanation to provide their insight in the comments below. My understanding in this respect has been guided by the helpful 2022 article How Disability Income Benefits Affect Employment for Persons with Disabilities in China: An Impairment-Based Work Disability Assessment Perspective which outlines that the Chinese welfare system’s minimum living standard called Dibao which (as I understand it) provides citizens with a disability with the minimum living standard’s welfare income provided that they are unable to work at all and they are unemployed. I haven’t been able to locate the exact current figure for this allowance, however, was able to find several articles from around 5-7 years ago saying it was in the vicinity of $160 (USD) per month. Lets contrast this against statistics from 2017 statistics published by the NDIS, which state that:

The average level of committed support per participant per annum is $54,000

Roughly translating that to USD, on a monthly basis, then adjusting for the difference in Australian to Chinese GDP (all at today’s value) this is ~$640. I realise this comparison is imperfect and I invite anybody with a better statistical analysis to comment their findings, however, on face value (with all the forementioned adjustments) the level of NDIS support is around four times greater than in China, and this is excluding the fact that a NDIS recipient may be able to receive additional welfare benefits and work in paid employment.

Perhaps there is a correlation between the potential financial gains in disability welfare systems, and the prevalence of disabilities in a given population. Or perhaps China is home to a significantly better health system than in the US and Australia.

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