Maria Kett

Managing the health effects of climate change

Climate change is the biggest global health threat of the 21st century. Effects of climate change on health will affect most populations in the next decades and put the lives and wellbeing of billions of people at increased risk. During this century, earthﾒs average surface temperature rises are likely to exceed the safe threshold of 2ﾰC above preindustrial average temperature. Rises will be greater at higher latitudes, with medium-risk scenarios predicting 2ﾖ3ﾰC rises by 2090 and 4ﾖ5ﾰC rises in northern Canada, Greenland, and Siberia. In this report, we have outlined the major threatsﾗboth direct and indirectﾗto global health from climate change through changing patterns of disease, water and food insecurity, vulnerable shelter and human settlements, extreme climatic events, and population growth and migration. Although vector-borne diseases will expand their reach and death tolls, especially among elderly people, will increase because of heatwaves, the indirect effects of climate change on water, food security, and extreme climatic events are likely to have the biggest effect on global health.

Disability and Poverty: the need for a more nuanced understanding of implications for development policy and practice

Abstract The international development community is beginning to recognise that people with disabilities constitute among the poorest and most vulnerable of all groups, and thus must be a core issue in development policies and programmes. Yet the relationship between disability and poverty remains ill-defined and under-researched, with few studies providing robust and verifiable data that examine the intricacies of this relationship. A second, linked issue is the need for—and current lack of—criteria to assess whether and how disability-specific and disability ‘mainstreamed’ or ‘inclusive’ programmes work in combating the exclusion, marginalisation and poverty of people with disabilities. This article reviews existing knowledge and theory regarding the disability–poverty nexus. Using both established theoretical constructs and field-based data, it attempts to identify what knowledge gaps exist and need to be addressed with future research.

Access to health care, reproductive health and disability: A large scale survey in Sierra Leone

This is the first study to compare health status and access to health care services between disabled and non-disabled men and women in urban and peri-urban areas of Sierra Leone. It pays particular attention to access to reproductive health care services and maternal health care for disabled women. A cross-sectional study was conducted in 2009 in 5 districts of Sierra Leone, randomly selecting 17 clusters for a total sample of 425 households. All adults who were identified as being disabled, as well as a control group of randomly selected non-disabled adults, were interviewed about health and reproductive health. As expected, we showed that people with severe disabilities had less access to public health care services than non-disabled people after adjustment for other socioeconomic characteristics (bivariate modelling). However, there were no significant differences in reporting use of contraception between disabled and non-disabled people; contrary to expectations, women with disabilities were as likely to report access to maternal health care services as did non-disabled women. Rather than disability, it is socioeconomic inequality that governs access to such services. We also found that disabled women were as likely as non-disabled women to report having children and to desiring another child: they are not only sexually active, but also need access to reproductive health services. We conclude that disparity in access to government-supported health care facilities constitutes a major and persisting health inequity between persons with and without disabilities in Sierra Leone. Ensuring equal access will require further strengthening of the countrys health care system. Furthermore, because the morbidity and mortality rates of pregnant women are persistently high in Sierra Leone, assessing the quality of services received is an important priority for future research.

Disability, vulnerability and citizenship: to what extent is education a protective mechanism for children with disabilities in countries affected by conflict?

Humanitarian crises as a result of conflict are often characterised by failure of the social contract between the state and its citizens. For a variety of reasons, children with disabilities are often particularly vulnerable in time of humanitarian crisis. This paper draws on research undertaken by the authors in a series of countries affected by conflict and looks at how the politics and policies of such countries, and the humanitarian and development agencies working in them, continue to exclude children with disabilities from formal and informal education structures. It will be argued that this exclusion not only impedes progress on inclusive education, but also has wider implications as education programmes are often the conduit through which a number of additional child protection mechanisms are implemented. Children with disabilities who are not in the formal education system are therefore at risk not only of missing out on education opportunities, but are also excluded from critical child survival initiatives, thus increasing their vulnerability.

Disability and public shelter in emergencies

This paper reviews current practice regarding people with disabilities in public (or communal) emergency shelter management. It shows that provision for disabled people generally fails to meet their needs and describes the main problem areas. These problems are set in the context of management and staff failings as well as underlying weaknesses in disaster management structures as a whole. The latter include outdated attitudes towards disability, the invisibility of people with disabilities to emergency officials and relief workers and misguided assumptions about the capacities of disabled people and their organizations to manage and respond to crises. The paper concludes with suggestions about how these challenges might be overcome.

The social and economic impacts of epilepsy on women in Nigeria.

BACKGROUND Persons with epilepsy in sub-Saharan Africa experience stigma and social marginalization. There is paucity of data on the social and economic impacts of epilepsy in these patients and in particular, groups like women. We sought to determine the social and economic impacts of epilepsy on Nigerian women and especially how it affects their treatment and outcomes. METHODS We carried out a cross-sectional survey of 63 women with epilepsy (WWE) and 69 controls matched for age, social status and site of care. A structured questionnaire was used to document information on demographic characteristics, education, employment status, economic status, health care use, personal safety and perceived stigma. The data were collated and analyzed with SPSS version 15. RESULTS Unemployment, fewer years of formal education, lower marriage rates and higher stigma scores were more frequent among WWE than controls. Physical and sexual abuse with transactional sex was also reported among WWE. We also noted poorer environmental and housing conditions and lower mean personal and household incomes among WWE compared to the control group. CONCLUSION WWE in this sample from Nigeria have worse social and economic status when compared with women with other non-stigmatized chronic medical conditions.

Water and sanitation issues for persons with disabilities in low- and middle-income countries: a literature review and discussion of implications for global health and international development

The critical importance of unrestricted access to clean drinking water and basic sanitation for all is highlighted in Millennium Development Goal 7, which calls for the reduction by half of the proportion of people without such access by 2015. Unfortunately, little attention has been paid to the needs of such access for the one billion people living with a disability worldwide, despite the fact that the right to equal access for all international development initiatives is guaranteed in the new United Nations Convention on the Rights of Persons with Disabilities. In this paper, we review what is currently known about access to water and sanitation for persons with disabilities in low- and middle-income countries from the perspective of both international development and global health, and identify existing gaps in research, practice and policy that are of pressing concern if the water and sanitation needs of this large - and largely overlooked - population are to be addressed.

Internally Displaced Peoples in Bosnia-Herzegovina: Impacts of Long-term Displacement on Health and Well-being

Several hundred thousand people remain internally displaced in Bosnia-Herzegovina living in camps and settlements. The public gaze of the media has long since moved on elsewhere and donors have shifted their resources. Displaced peoples have specific burdens over belonging, housing, occupation, welfare, security and loss of communities. The decision whether to return to their homes is complex, with local and international political pressures adding to their uncertainties and insecurities. In addition there is the impact of the war, the experiences of violence, the remembering and issues of reconciliation, and a variety of mostly unevaluated psychosocial programmes aimed at helping with these. All this has a profound impact on their health and well-being. Understanding these processes and the views of chronically displaced people themselves should guide policies of post-conflict management to plan for the longer term and to be more focussed on the human factors rather than simply rules and properties.

Policy Development: An Analysis of Disability Inclusion in a Selection of African Union Policies Inclusive

Contemporary debates in international development discourse are concerned with the non-tokenistic inclusion and participation of marginalised groups in the policy-making process in developing countries. This is directly relevant to disabled people in Africa, which is the focus on this article. The United Nations Convention on the Rights of Persons with Disabilities delineates the principles of inclusion in society. Furthermore, the African Union (AU) plays a key role in advising its Member States and with regard to disability issues, whose advice should be reflected in disability-inclusive policies. This paper analyses nine policy or strategy documents produced by the AU, covering the policy domains of education, health, employment and social protection that are crucial to the development of disabled people. These were analysed according to seven discrete elements (rights, accessibility, inclusivity, implementation plans, budgetary allocations, enforcement and disaggregated management information systems) using a rating scale of one to four with four being the highest level of inclusion. The process (for example, level of consultation), the context (for example, the Millennium Development Goals and the Sustainable Development Goals) and actors involved in the policy development were reviewed as far as was possible from the documents. None of the policies reached even 50% of the total possible score, indicating poor levels genuine of inclusion. Rights scored a highest rating but this is still at a low level. This suggests that there is recognition of the rights of disabled people to inclusion, but this is not generally integrated within inclusive implementation plans, budgetary allocations, enforcement mechanisms and disaggregated management information systems for monitoring. The limited socio-economic inclusion of disability within AU policies is indeed a lost opportunity that should be reviewed and rectified. The findings have broader ramifications for the non-tokenistic and genuine involvement of poor and marginalised groups in the international policy-making arena.

Consigned to the margins: a call for global action to challenge intellectual disability stigma

Stigma as an important public health concern has been recognised in relation to conditions as diverse as HIV, leprosy, and mental illness. Little attention has been paid to date, however, to the pernicious eff ects of stigma on the wellbeing and life chances of one heavily stigmatised population: people with intellectual disabilities. Of the 15 billion people globally aff ected by disability, an estimated 2%, or 300 million, have an intellectual disability. They experience the same disadvantages and inequities as do people with other types of disabilities, but often face the additional disadvantage of having their needs inadequately understood and met, having limited recourse to assert their rights, and being poorly represented, including within the Disability Rights movement. The majority live in low-income and middle-income countries where there is little impetus or resource to assess or diagnose their struggles in meeting the cognitive, social, and economic demands of everyday life. Whether labelled intellectually disabled or not, they are generally among the most marginalised groups within society, experiencing high levels of health, social, and fi nancial inequities. The 2008 UN Convention on the Rights of Persons with Disabilities (CRPD) requires governments to raise awareness of disability and challenge prejudice and discrimination (Article 8), and to ensure equal and eff ective legal protection against discrimination (Article 5). Earlier global comparative data on attitudes to intellectual disability is limited to a study from 2003, which included ten countries across four continents, and to a 2007 WHO Atlas, focusing on resources but including some indicators of attitudes. To determine current issues related to persons with intellectual disabilities, we undertook a global study, examining government action as reported to the CRPD Committee and gathering data from 667 disability experts and organisations from 88 countries regarding the extent to which low awareness of intellectual disability and stigma are continuing concerns, and what is being done to tackle these concerns. The results indicate that in many (mostly high-income and uppermiddle-income) countries the general public agrees with inclusion in principle, but often view it as impractical and unachievable. A “not in my own backyard” attitude and a fear that inclusion of people with intellectual disabilities may aff ect the resources and achievements of those without disabilities, particularly in school and work environments, persists. Of equal concern, in many middle-income and lowincome countries, children and adults with intellectual disabilities still face high levels of stigma and denial of fundamental rights and freedoms. Their invisibility is accompanied by low expectations of people with intellectual disabilities—in many countries they are still widely viewed as incapable, unable to live independently or to contribute to society. Furthermore, throughout Africa and Asia, in former states of the Soviet Union, and in some parts of South and Central America, an active desire to segregate them from society continues because of deep rooted prejudice and stigmatising beliefs about the causes of intellectual disability. Our data suggest that eff orts to combat intellectual disability stigma in such countries are small in number and entirely dependent on parent organisations and non-governmental organisations. The imbalance between the world regions where intellectual disability stigma is of greatest concern and where eff orts are underway to tackle such stigma is evident the fi gure, which categorises interventions reported to us by world region.