Disability, poverty and inequality models

In the scoping review, the relationship between poverty (inequality) and disability was identified as foundational to more critical models of disability.12,327,407–409_{Such models emphasise a strong connection}

between inequalities and disablement and a particularly strong association with‘entrenched poverty’. These concerns are reflected in the public health literature and this is another important point of potential cross-linkage. For example, children living in poverty who already have an illness or health condition are particularly susceptible to disability.19,399,410_{Income inequalities have also been found to be linked to}

conditions such as mental health or obesity.411_{Furthermore, disability can affect families in terms of the}

extra health costs of impairment, time spent caring and loss of income,409_{and, more generally, families}

that have a disabled family member are more likely to live in poverty.1,412

Consequently, this experiential and statistical association between chronic poverty and disability, as well as its intersections with other dimensions of disadvantage,413_{would seem fundamental to understanding the}

processes of impairment and disablement408_{and their wider complexity in differing local and global}

contexts.414_Yeo,408_{for example, argues that a person with disabilities faces discrimination, which leads to}

multiple forms of exclusion. Institutional, environmental and attitudinal barriers, for example, result in disabled individuals not having the same opportunities as everyone else, which means that they are more susceptible to poverty, which in turn negatively affects their health. Whiteheadet al.415_{and Yeo}408_both

view this as a cyclical or spiral dynamic of political, sociocultural, economic and environmental processes. Adapting the above in terms of a multidimensional matrix (not necessarily cycle or spiral) means that the situational factors linked to impairment become embodied and potentially (but not necessarily) linked to disability discrimination, which in turn further increases susceptibility to inequalities and the possibility of chronic deprivation. Setting out the factors that can lead to inequality, ill health and disease416_{also helps}

to identify what constitutes enabling environments, explaining why some people who have impairments thrive or are resilient and flourish (Figure 6provides a visual representation of these arguments).

Poor health, mental health issues and/or impairments have all been identified as factors that increase inequalities.417–420_{MacInneset al.}420_{note that a plethora of issues needs to be tackled but that}

‘early interventions’, such as those in workplace settings to prevent physical impairment or mental health issues, in addition to more‘responsive health care systems’, can contribute to tackling inequalities. Similarly, it was noted that (vocational) rehabilitation can help to ensure that people do not become incapacitated

Individual diversity Individual–relational

Social–relational Social–environmental Political and economic

after sickness leave.409,420,421_{This is consistent with a public health agenda and explains why inequality}

models linked to disability have relevance when evaluating public health interventions, particularly when assessing the potential impact of interventions, and this can be joined with an analytical framework by which to explain disabling experiences.

Difficulties, however, begin to occur over the use of metrics that are used to inform connections between disability and inequalities. As we have seen (seeChapter 3), those who assume a more critical perspective criticise such measures as (dis)ablest and failing to capture the lived experiences of disabled people, while implicitly making assumptions about burden and normality. Measures facing particular criticism include disability-adjusted life expectancy, healthy life expectancy and disability-free life expectancy.422_{As noted,}

all are seen to reinforce a negative understanding of disability by focusing on the difficulties associated with having a disability rather than on the potential of emancipatory activities to change the social environment. Such measures are also criticised for struggling to accommodate a more dynamic account of disabling experiences, in which disability is likely to be experienced by most people at some time in their lives.1_{Furthermore, the link to inequalities or understanding disadvantage can sometimes be}

oversimplified, especially if interpreted within the context of a short-term, narrow, cost-focused analysis linked to disability measures, rather than the long-term need for accessible and appropriate care.423

• Intergenerational • Historical • Socioeconomic • Geographical

• Become politically neglected • Interlink with individual, relational, social and structural marginalisation

Limited accessibility to • Education

• Employment (formal and informal)

• Land and shelter • Sanitation • Health care

• Sufficient and nurtritious foods • Political and democratic process, etc.

• Forced immobility and lack of accessibility of environment • Forced to accept hazardous, dirty and dangerous working conditions

• Forced unemployment • Lack of ability to understand, access, assert and have rights defended

• Malnutrition, poor health and physically weak • Inability to live well

• Inability to plan for future or save money for life ‘shocks’ • More susceptibility to life ‘shocks’ and adverse events along the life-course

• Psychoemotional disablism • Physical and social exclusions • Overt disablism

• Vulnerability to hate and other crimes

• Links to other forms of discrimination such as racism, sexism and LGBT discrimination 1. Chronic deprivation 4. Entrenched inequalities 3. Disability discrimination 2. Increased susceptibility to impairment(s)

FIGURE 6 The chronic deprivation/entrenched inequalities matrix (adapted from Yeo408_).

Recent critical literature from disability studies would prefer to explore inequalities by questioning the able-bodied norms and values which they see as implicit in standard health-related measures. This critical literature also notes a perceived all-embracing concern with‘ability’to work,290_{adherence to variations of}

a capabilities approach that still focuses on functioning413_{or a misplaced emphasis on producing fine}

graduations of debility and capacity.383_{This is why, when exploring inequalities and disability, more critical}

debates emphasise the importance of considering the norms and values implicit in interventions and evaluations designed to measure their effects, alongside the broader value of more inclusive practices associated with a human rights-based approach.