A Disability Studies Perspective on Employment Issues and Policies for Disabled People: An International View

Kay Schriner. Handbook of Disability Studies. Editor: Gary L Albrecht, Katherine Seelman, Michael Bury. SAGE Publications. 2001.

Employment concerns are of paramount importance to disabled individuals around the world. How will they get the opportunities, training, and experience necessary to engage in farming or fishing, get a job, or start their own businesses? How will negative attitudes affect their abilities to support themselves or their families? How can they be appreciated for what they can do rather than become objects of pity and subjects of charity? How can their communities become more accessible and responsive to their desires for true integration and equality in all of society? The ability and opportunity to participate in the economic life of their communities are indeed central to the quality of life lived by disabled people.

The purpose of this chapter is to provide an overview of employment issues facing people with disabilities internationally; place these issues in the context of major political, economic, and social circumstances and trends; and analyze employment policies designed to improve conditions for people with disabilities. Special attention will be paid to the majority world because of estimates that 80 percent of people with disabilities live in those countries (United Nations 1986). I will discuss the approaches that appear to offer the most promise and argue for solutions that respect the integrity of disabled individuals and their families, demonstrate cultural competence, recognize the importance of promoting the economic independence of individuals with disabilities and their communities, and promote social justice. Finally, I will emphasize the centrality of putting disabled individuals at the center of the problem-solving process as societies struggle to improve conditions for them and their families.

Who is Disabled?

Definitional issues are among the thorniest questions in any discussion of employment because of the practical and policy relevance of such definitions. The debate about how to define disability has been raging for many years and has not been resolved. Scholars and policymakers are beginning to agree that definitional schemes must incorporate interactions between individuals and their environments (defined broadly to include architectural, programmatic, and attitudinal variables), but as yet, there is no agreement on how to operationalize this concept of disability.

In an emerging paradigm, disability is viewed as the end result of the lack of societal institutions and practices to accommodate the full range of individual differences (Higgins 1992; Scotch and Schriner 1997). This human variation paradigm defines disability as the result of institutions “having been constructed to deal with a narrower range of human variation than is in fact present in any given population” (Scotch and Schriner 1997:155). While still in the nascent stage of development, the human variation model offers an alternative to analyzing all disability-related problems as medical, economic, or discrimination problems.

The issue of contextualizing definitions of disability arises when estimating the number of people who are disabled with respect to work. The Canadian Health and Activity Limitation Survey, for example, asks whether an individual is restricted in hearing, seeing, moving, working, and so on, as would any “normal” person (Crichton and Jongbloed 1998:230), which yields the estimate that about 10 percent of the population has a disability. In the United States, estimates are that about 10 percent of people ages 16 to 64 have such a disability. Disability is defined as “a limitation in the amount or kind of work they are able to perform, due to a chronic condition or impairment” (LaPlante et al. 1996:1).

The contextual challenges of defining disability become clear on closer examination of U.S. work disability data. One such instance is the finding that there are “weak correlations between individual physical or mental attributes and work disability at the empirical level” (McDonough 1997:78, emphasis added). Future research will be directed to sorting out the causal relationship between environmental variables such as the availability of work (e.g., Yelin 1992) and the pull of family roles (McDonough 1997) on individuals’ perceived and actual ability to obtain and maintain employment.

These observations have been noted for the data being generated in developed nations, but what about the information on work disability as it applies to developing countries? Researchers have noted that the economies of many countries in the developing world are agriculturally based and have very high rates of unemployment in the formal sector. Also, many people (with and without disabilities) may not be participating in the formal economy (Barnartt 1992), which speaks to the need to consider adaptations to U.S.-style questions when estimating the prevalence of work disability in another culture. (Devlieger [1998] refers to a Zimbabwe survey that identified some 250,000 individuals with disabilities in that country, about 40,000 of whom “have lost skills and productive capacity”) Furthermore, there are no good data on the incidence or prevalence of impairments in most countries (Barnartt 1992; Coleridge 1993).

These facts illustrate the difficulty in arriving at reliable and valid estimates of the number of people who have work disabilities in any given country. Each set of national data would need to reflect how individual differences interact with environmental conditions to affect the ability to participate in the economic sphere, and this interaction will no doubt vary from country to country. The interactions between social context and impairments will be vitally important, for as Groce (1995) explains,

A spinal cord injury resulting in paraplegia may prove far more disabling, both socially and economically, to an impoverished sugar cane cutter than to a college professor. The loss of sight for an impoverished washerwoman living in a shanty town might place significant burdens on her family and friends. Unable to work at her former trade and needing assistance to work within the house, watch children or negotiate in the world outside, her standing and status within the family and community might be significantly altered. A wealthy woman with an identical loss of sight, may find the disability far less incapacitating. Her loss of vision may place her at no real disadvantage in terms of socio-economic survival, nor might the well being of her family be substantially compromised. Indeed her need for assistance to maintain a household or career may create jobs for one or several additional individuals. (P. 1136)

Another complication is that national work disability rates are not static. Demographic changes are reverberating through the population, resulting in new incidence and prevalence rates in various age groups and new patterns of etiology within those groups. Especially in the developed world, improved health care and socioeconomic conditions are “aging” the population, which increases the number of individuals with disabilities since disability is more likely to occur as one ages.

Other factors also are contributing to changes in the size and characteristics of the group of people who are disabled. Current military conflicts are an especially important concern in Africa and parts of Eastern Europe, and the aftermath of war in Asia also continues to produce disability because of the many remaining land mines. Nonmilitary violence is also an issue. In the United States, for example, there have been questions raised about possible implications of the high rate of injuries caused by firearm violence and the ability of the vocational rehabilitation program to respond to the victims (Groce 1999).

The socially constructed nature of disabilities, as well as the variations in the way disability is produced through demographic and cultural forces, supports Barnartt’s (1992) contention that “one definition [of disability] which fits all countries or situations will not be found” (pp. 47-48), but perhaps this is less problematic than it appears, for as Coleridge (1993) concludes, “No matter what the actual number of disabled people in the world, the case for civil rights is the same” (p. 103).

Employment Issues Facing People with Disabilities

No matter whether they live in the most prosperous nations of the world or the least, people with disabilities are among the most economically disadvantaged groups in society. In developing nations, there are few data from government sources regarding the socioeconomic status of individuals with disabilities. There are indications, however, that many people with disabilities occupy a marginalized status in those nations. For example, one African service provider indicates that in urban areas, the unemployment rates for people with disabilities are “five times more than for others” (Campos 1995:71).

In many developing nations, conditions for women with disabilities are worse than for disabled men—both generally and specifically with regard to economic self-sufficiency. Many of these women have very limited or no access to health care, putting their very survival at stake (Groce 1998). Because of legal and cultural limitations on their right and ability to participate in the labor force, such women also have much less earning power throughout their life span (Groce 1998). When they do work outside the home, they are more likely to toil in dangerous occupations with few opportunities for improvement in their economic circumstances. And rates of “unemployment” for women with disabilities may not reflect the significant contributions they make to their families’ well-being by engaging in homemaking, child care, and other home-based activities—whether or not these contributions are noticed or appreciated by governments, neighbors, or their own family members (Groce 1998).

A fact that complicates the question of the employment status of disabled people is that the nature of work in developing nations is very different than in postindustrial economies where the information age is in full swing. Many people around the world work at subsistence activities such as farming or fishing or are self-employed as merchants or artisans, so estimates of work disability in those economies should reflect these primary economic roles.

The data concerning the employment conditions for people with disabilities in the developed world are generally more available, though no more encouraging. In Western countries, people with disabilities are chronically underemployed and unemployed. In Britain, two-thirds of people with disabilities do not work, though a government survey found that one-half of these individuals expressed an interest in working (Gooding 1994). Also, people with disabilities were more likely to be employed in manual or unskilled occupations and less likely to hold professional or managerial positions. Only about one-third of workers who become disabled as adults retain their jobs. A survey conducted by the Association of Disabled Professions found that one-third of those responding believed that their “intellectual abilities and professional training” were not being fully used (Gooding 1994:6).

Figures from the United States and Canada are similar. In the United States, unemployment rates among working-age persons with disabilities continue to be very high, despite advancements in assistive technology, rehabilitation practices, and the antidiscrimination provisions of the Americans with Disabilities Act. A recent national survey indicates that while more than 80 percent of the general population is employed, only 3 in 10 working-age adults with disabilities are employed (Louis Harris and Associates 1998). In Canada, while nearly 70 percent of nondisabled individuals have jobs, only 40 percent of persons with disabilities are employed (Crichton and Jongbloed 1998).

Unemployment rates vary among subgroups of people with disabilities. A report from the United States shows much lower employment rates for people with severe disabilities and African American and Hispanic individuals with disabilities (McNeil 1997).

A consistent finding is that women with disabilities are less likely to be employed than are other subgroups of disabled people or nondisabled individuals. In Canada, fewer than 31 percent of working-age women with disabilities are employed, compared with almost one-half of men with disabilities, while 60 percent of nondisabled women and almost 80 percent of nondisabled men have jobs (Crichton and Jongbloed 1998). In one study, Canadian women were found more likely to report they were unable to engage in paid work if they “were not living with children and [were] structurally disadvantaged according to low levels of education” (McDonough 1997:89). In the United States, disabled women from minority groups are particularly disadvantaged (National Institute on Disability and Rehabilitation Research 1992).

Furthermore, having a disability is also associated with lower earnings for those persons with disabilities who do work. English studies show that people with disabilities who work earn only about two-thirds the wages of nondisabled persons (Gooding 1994). In the United States, while the median monthly income among nondisabled men ages 21 to 64 in 1994 and 1995 was $2,190, those with a nonsevere disability earned only $1,857, and those with a severe disability earned only $1,262. Similarly, nondisabled women in the same age group earned a median monthly income of $1,470, while women with nonsevere disabilities earned $1,200. Women with severe disabilities earned only $1,000 per month (McNeil 1997).

Even when disabled individuals are working, they are often apt to be working fewer hours than others. This is true in Canada, where almost 81 percent of women with disabilities (as compared to about 61 percent of nondisabled women) and about 60 percent of disabled men (as compared to 31 percent of nondisabled men) work part-time, that is, less than 30 hours per week (Crichton and Jongbloed 1998:246).

In sum, it does not seem to overstate the case to say that people with disabilities are almost universally on the bottom rung of the socioeconomic ladder. The combination of empirical and anecdotal evidence clearly indicates that throughout the world, disabled people are less likely to be employed in valued roles in their nations’ economic activity than are their nondisabled counterparts. The agendas of governments, private relief organizations, and disability rights groups will rightly focus on questions of economic independence and interdependence in the years to come.

Why are People with Disabilities So Likely to be Unemployed?

Developing effective strategies for improving the employment circumstances of people with disabilities requires an appreciation of the social, economic, and political factors that conspire to keep them marginalized. In this regard, the most important contribution of recent years is the now-flourishing scholarly pursuit of a contextualized understanding of disability. In stark contrast to the knowledge bases of the disability professions, such as special education and rehabilitation—which threaten to become moribund soon without an infusion of significant new ideas and strategies—disability studies has yielded important and fresh perspectives on disability in society.

These insights begin with the fundamental notion that disability is socially created. In the past, we rarely questioned the designation of impairment as a disability. We knew that mental retardation, mental illness, deafness and blindness, and physical impairments were “problems.” We drew from this analysis the faulty conclusion that if we corrected the individual’s limitations through medical treatment and rehabilitation, the “disability problem” would be solved. The devaluation of particular forms of individual differences was easily explained and almost as easily justified; after all, who would question that these differences were problematic? It seemed to be the natural order of things to mark individuals with such differences for different treatment, good and bad.

Now, we know that disability is not located exclusively in the individual. Rather, some individual differences are marked as disabilities through a complex interchange of social, economic, and political processes (Corker 1998; Oliver 1996; Priestley 1999; Rioux and Bach 1994). Disability is created. Furthermore, the disability category can be contested (e.g., as it is in the case of learning disabilities) in ways that clarify these processes. The old truism of disability, then, is an illusion. If societal conditions produce disability by attaching to some impairments architectural, programmatic, and attitudinal disadvantage, we must know more about these structural impediments, where they came from, and how they can be removed. Such an understanding is imperative if the employment issues facing disable people are to be meaningfully addressed.

Culture

A primary concern must be to develop a culturally informed perspective on disability and culturally competent employment programs and policies. Cultural factors are bedrock to disability studies by virtue of their importance in illuminating the social bases for the disadvantages associated with individual differences. By developing culturally specific knowledge about disability, we can reflect on and assess our successes and difficulties in addressing employment issues and improve on promising approaches.

One mechanism for developing sucha knowledge base is the historical and critical analysis of disability portrayals in media, literature, and other carriers of culture. Represented in important recent works, such as the collections by Mitchell and Snyder (1997) and Thomson (1996) (and also addressed in other chapters in this volume), this scholarship promises to unveil the social processes that support the stigmatization and marginalization of people with disabilities.

Understanding cultural influences is also important for understanding societies’ definitions of disability and the circumstances in which disabled people live. Cultural factors not only dictate how the cause of an impairment will be understood but also whether the impaired individual will even survive—and will survive until adulthood—the social roles designated as appropriate for that person (Groce 1993). Groce (1993) describes some particular cultural responses to impairment:

In societies where belief in reincarnation is strong, such as among Southeast Asian groups or in Indian society, a disability is frequently seen as direct evidence of a transgression in a previous life, either on the part of the parents or the child. Those who are disabled are frequently avoided or discounted because of their past lives, while they are simultaneously urged to lead particularly virtuous lives this time around. Answerable both to the past and the future, too little time and energy are often devoted to improving life in the present. (P. 1049)

Even within a cultural group, class membership may produce very different experiences. As Groce (1998) notes,

A woman’s social and economic class, her marital status, her family’s social networks, her level of education, and her specific type of disability will make a dramatic difference in her quality of life and her ability to make choices. For example, even within the same community, the quality of life for a rural peasant woman with multiple sclerosis will usually be dramatically different than that of the wife of a prominent politician. A daughter with mild mental retardation born into a wealthy family may be well cared for and even put under the supervision of a full-time companion (whether she wants this or not) to ensure her comfort and safety. A daughter of a family living in a nearby shanty town with a comparable degree of mental retardation may well find herself on the streets and at risk of abuse and prostitution by her early teenage years. (P. 179)

Similar observations may be made about men with disabilities. A man who is disabled may be considered a shame to his family, even when his impairment is acquired in war (Barnartt 1992).

It must be said, however, that not all understandings of disability are negative. Some explanations for impairments (especially what we today label as “mental illness” or “mental retardation”) describe them as gifts from a divine source. Ingstad (1990) describes the reaction of an African mother to the birth of her disabled daughter:

When African people talk about God’s will they seem to place a much more positive emphasis on it than do Europeans. God’s will is not seen as a punishment, but more as God’s trust in the parents’ ability to take care of a special child. Thus a Botswana mother who gave birth to a child with very deformed feet called her “Mpho ya modimo,” a gift from God. (P. 191)

Public Policy

Governments play an important role in affecting the likelihood that people with disabilities will be active participants in the economic lives of their communities. They may recognize people with disabilities as a category of citizens and develop strategies for addressing their needs and concerns, or they may largely or completely ignore the population of disabled individuals within their national boundaries. In either event, governments help determine what happens to people with disabilities.

Many Western nations have established elaborate disability policy systems that directly (in the case of income maintenance and rehabilitation programs) and indirectly (in the case of health care, transportation, housing, and education programs) affect the employment circumstances of people with disabilities. These systems are characterized by their histories of incremental policy development over decades in a patchwork fashion by bureaucrats and professionals with little influence from individuals with disabilities. As Berkowitz (1987) notes,

In disability, as in social welfare in general, the only avenue of fundamental reform [has been] to add another program to existing programs and to cope with the resulting confusion … Because of these tendencies, our disability policy, viewed in historical context, consists of layers of outdated programs. (P. 227)

As will be discussed in more detail later, the disability policy in many Western countries now poses significant challenges to policymakers, service providers, and people with disabilities who wish for more coordination and consistency between and within publicly funded programs. In countries such as Sweden, Germany, and the United States, there are significant disincentives to work in public policy. Social insurance programs that provide income support conflict with rehabilitation programs. In some instances, income maintenance is tied to the receipt of health care. These conflicts in purpose and function result in significant disincentives to workforce participation, particularly when access to health insurance is tied to receipt of disability-related income benefits.

The situation in developing nations is quite different. On one hand, they may have the comparative “luxury” (if it can be called that) of not facing the problem of stagnant public policies. On the other hand, these countries have significantly fewer economic resources to spend on national programs dedicated to people with disabilities. They tend to be much more concerned with economic development, education, and basic health care than with the “special” needs of people with disabilities (Barnartt 1992; Metts and Metts 1998). In fact, funds for disability programs in these countries come primarily from the donations of non governmental organizations (NGOs) such as international aid groups, missionaries, and government programs sponsored by developed nations (Barnartt 1992). Because the developing nation typically has little or no control over the activities of NGOs, their ability to be proactive is limited.

Still, it is by no means the case that countries in the majority world do not demonstrate concern and commitment to disabled people. Developing countries are establishing publicly funded programs for disabled people (which, although representing a growing awareness, are apparently reflecting some of the “unintended and unfortunate consequences” of specialized services in Western nations) (Ingstad 1990). It is equally important to realize that, as Devlieger (1998) notes with respect to Zimbabwe, in many countries, the provision of assistance and support is an inherent part of the survival strategies of native people. This cultural resource, when viewed as a part of a nation’s informal disability policy, becomes a potent force in meeting the needs of disabled people.

Impairments

Whether impairments are important is the subject of some debate. Some scholars argue that the primary determinants of employment outcomes are prejudicial attitudes and discriminatory behavior directed at individuals with disabilities. From this perspective, the removal of discrimination barriers through policy and other tools is a necessary and, some would say, sufficient step to making it possible for disabled persons to get and keep jobs.

Alternatively, others argue that impairments are indeed important (though they acknowledge the very detrimental effects of disability discrimination). This point of view holds that the individual differences that we typically label as disabilities (e.g., cognitive impairments, physical disabilities, psychiatric impairments, communication disorders) do in fact matter, and there is some evidence that people with disabilities themselves believe this to be the case. Walter Oi (1991), for example, who is blind, argues that “disability steals time” (p. 31). A Canadian report cautions that “most Canadians who are not in the labour force regard themselves as being completely unable to work, while others are involved in activities which makes it unlikely that they would or could take a job if one was offered to them” (cited in Crichton and Jongbloed 1998:247). Surveys conducted in the United States add support to this notion; the latest Harris survey reports that “an overwhelming majority (85 per cent) of people with disabilities who are not working say that an important reason why they are not working or looking for work is that their disability or health problem severely limits what they can do” (Louis Harris and Associates 1998:43).

The question of whether impairments matter, requiring us to choose between societal-level factors such as discrimination and individual-level factors, sets up a false dichotomy, however. It is not necessary, nor is it a good idea, to pose the question in this way. Rather, we should be searching for some resolution to the broader question of why some impairments seem to matter for some people in some circumstances and what this understanding implies for developing solutions to the employment problems people with disabilities experience.

We know, for example, that in industrialized countries in the West, the disability category serves an important economic and political function by demarcating those individuals who will be freed from the obligation to participate in the workforce as part of the “deserving poor” (Stone 1984). People with certain impairments that are inconsistent with the production needs of society are thus excused from the work-based system of reward and allowed to participate in the need-based system of social welfare programs (most notably, disability insurance schemes). The disability category collects and sorts the cognitive, communication, physical, and emotional differences that “matter” in the economic arrangements of a nation.

Once these impairments are assembled (and an administrative structure put in place to “objectively” document them), governments may provide these individuals with an exit from the workforce and services designed to help some of them reenter the workforce. The political responses objectify in public policy what the processes and institutions of production have already made real—the devaluation of some forms of individual difference based on their economic implications. It should be no surprise, then, that people with disabilities in these countries are more likely to be unemployed or underemployed. Indeed, it is the very purpose of the disability category to separate them out of the workforce—at least in industrialized economies (Stone 1984).

Furthermore, production methods influence the degree to which individual differences can be accommodated in a society’s workplaces. Ingstad (1990), reflecting on the simple technologies used in earlier times in Europe, characterizes the situation of disabled people in these “close knit rural communities” as “natural integration” (p. 188). In regard to industrialized economies, Ryan and Thomas have argued that the organization of work in the new factories was less accommodating than the less rigid ways of agrarian life:

The speed of factory work, the enforced discipline, the time keeping and production norms—all these were a highly un favourable change from the slower, more self-determined and flexible methods of work into which many handicapped people had been integrated. (Quoted in Gooding 1994:13-14)

What is less clear is how and why the disability category has evolved in the way it has or what these histories imply for current policies in other countries whose economic structures have been subjected to less interpretation by disability studies scholars. As Gooding (1994) notes, “There have been no detailed historical studies of the effects of changes in the modes and relations of economic production upon the integration of disabled people into the labour market” (p. 13). Clearly, this is an important topic for future research.

Public Policies Affecting Employment of People with Disabilities

Commonalities in European and American Approaches

Employment has been on the center stage of disability policy in industrialized nations for a ry long time. With the exception of veterans’ benefits, no other focus has been more prominent or longstanding than employment. Western societies use several strategies to address this issue, including social insurance, vocational rehabilitation programs, hiring quotas, tax credits for employers or individuals with disabilities, and antidiscrimination protections. Yet underemployment and unemployment persist as serious problems for most people with disabilities.

The approach taken by Western nations to dealing with the employment participation of workers with disabilities typically consists of a combination of ameliorative and corrective strategies (Haveman, Halberstadt, and Burkhauser 1984). Ameliorative responses include workers’ compensation, disability insurance programs, and health care coverage. These provide workers with disabilities partial replacement of lost income and medical services on either a temporary or permanent basis. Also included in the ameliorative category are welfare programs such as the U.S. means-tested Supplemental Security Income.

Corrective programs are those intended to rehabilitate workers who become disabled during their adult years or to habilitate individuals whose disabilities are congenital or acquired at an early age. The most important of such efforts are the national rehabilitation programs that provide counseling, restoration services, education or vocational training, and placement services to eligible individuals with disabilities. A complementary strategy is to institute legal protections against disability-based discrimination in the workplace in an effort to promote the use of accommodations; perhaps the most notable example of this approach is the U.S. Americans with Disabilities Act.

This general outline of disability policy with respect to employment obscures important differences in the particulars of these various programs. A comparison of approaches in Sweden, Great Britain, Holland, West Germany, and the United States illustrates the range of policies. Each of these countries includes social insurance and welfare programs in the mix, but the emphases differ.

Historically, Holland and Sweden have had more generous income replacement policies for people with disabilities who have participated in the labor force. Their benefit levels (i.e., percentage of predisability income replaced by disability insurance payments) are higher than in West Germany, Great Britain, or the United States. By contrast, Germany and England both place more emphasis on rehabilitation, although Germany’s program is generally regarded as more effective (Aarts and De Jong 1996).

While it is not possible to discuss in any detail the intricacies of Western-style disability policy, it is useful to briefly identify the major points of the criticisms leveled against these approaches in recent years. In the United States, where health care benefits are tied to participation in income maintenance and disability insurance programs, politicians and the disability community have focused on removing the disincentives to workforce participation. Restructuring incentives is also a major concern in Sweden and the Netherlands. In Germany and in the United Kingdom, where workforce participation rates are higher, the question of incentives has been less important. The Swedish and Dutch programs are concerned with improving the efficiency and fairness of their administrative structures (Aarts and De Jong 1996). In commenting on the complexities of managing disability programs, Aarts and De Jong (1996) remind us that

good social policy and practice … not only require able administrators, using appropriate policy tools, but an intelligent design of the incentive structures implied both by the programs and by their management. This may seem obvious, but it took about three decades before this insight finally broke through among European [and U.S.] supporters of the welfare state. (P. 159)

Disability Policy in the Majority World

Unlike the wealthier nations of the world, most countries do not dedicate significant funds to programs targeted to people with disabilities. Many African nations are simply unable (and perhaps unwilling) to spend national resources on programs specifically for individuals with disabilities (Barnartt 1992; Metts and Metts 1998). In these countries, nongovernment organizations (NGOs) are active in meeting the needs of disabled people and their families. Much of this activity occurs in the context of economic development initiatives (Metts and Metts 1998). For example, NGOs (such as the United Nations and its various component programs) and the U.S. Agency for International Development (USAID) provide funds, technical assistance, and personnel to countries throughout Africa to help promote the establishment of economic infrastructures and programs. Increasingly, these programs are being pressured to include people with disabilities in their governance and as targets of programmatic activities (Metts and Metts 1998), but there remains considerable prejudice and misunderstanding regarding disabled people. Peter Coleridge (1993), who has worked in international disability programs for a decade, reports the following:

In many developing countries disability is often perceived by governments and aid agencies as a problem, but not as a priority. Income, access to land and/or jobs, basic health care, the infant mortality rate, and the provision of sanitation and clean water are all seen as greater and absolute priorities. These are the pressing problems, and disabled people can be attended to later … Even people who are “progressive,” “gender-aware,” and in all other respects “developmentally minded” perceive disabled people as belonging to a category marked “social welfare,” which is the new term for “charity.” The implication is that disabled people can be ignored altogether in the development debate. (P. 5)

The problem is compounded by the fact that economic aid is often focused on large-scale projects, but the needs of disabled people are considered a local problem. Metts and Metts (1998) quote a U.S. government source who draws the conclusion that USAID officials believe that the focus on “helping the population of developing countries by improving their overall economic condition … may work against the inclusion of the disabled where the primary focus is on the grassroots level” (p. 32). At any rate, the lack of understanding of aid officials remains a problem in these countries.

The majority world’s primary approach to rehabilitation is changing. Having seen the difficulties produced by over-professionalization and specialized services in the Western world, a community-based rehabilitation (CBR) strategy is slowly replacing older practices. In this model, the communities in which disabled people live are provided technical assistance by rehabilitation professionals, who help “ordinary people” such as family members, neighbors, and teachers, develop the skills necessary to accommodate the disabled person (McConkey and O’Toole 1995). The rehabilitation professional focuses more on the community through consultation, building relationships, developing and using training skills, nurturing the family’s and community’s capacity to cope, and promoting community “ownership” of the person with a disability (McConkey and O’Toole 1995). Supported by international aid agencies, CBR is moving the majority world away from the tradition of “rehabilitation palaces” (Werner 1995:18) to a greater reliance on localized, consumer-driven strategies.

Remaking “Rehabilitation”: A Call for Transformative Rehabilitation Practice

Rehabilitation Past and Present

The disability policies of nations around the world have been affected by a long pattern of international relations between disability professionals and organizations representing people with disabilities. In fact, Groce (1992) argues that rehabilitation is in actuality an invention of these international connections:

The historical distinction between national and international rehabilitation activity is somewhat artificial. For many years ideas flowed from one arena to the other and back again … Ideas, approaches and concerns that American leaders were instrumental in developing within the United States, were carried on into their work abroad. Likewise, ideas and innovations to which United States leaders were exposed in international rehabilitation programs were often quickly incorporated into programs in the United States … it should [also] be noted that [there has been a] shift over the past century within the field of disability and rehabilitation from a group of fragmented programs, disciplines and experts, to an increasingly unified disability rights movement. (P. 5)

As a field of theory and practice, though, it seems apparent that around the world, rehabilitation has been overly influenced by Western ideals and ideas. The medical model of disability, the development of professions in health and disability services, and the prominent role of the state in providing services and benefits to disabled persons are largely Western creations. However, majority countries have had mixed experiences when they attempt to adopt the rehabilitation approaches of the United States, England, and other developed nations. Often they find that the establishment of a professional class of rehabilitation workers is financially impossible (Barnartt 1992; McConkey and O’Toole 1995). In some instances, when funds are expended to train rehabilitation professionals, countries find that the professionals become dissatisfied with the relative lack of attention and status associated with their roles or are enticed to take jobs in other countries because of better pay and better working conditions (McConkey and O’Toole 1995).

Developing nations have also struggled with decisions about where to establish rehabilitation programs and their relationship to broader education and social service efforts. In many countries, most or all rehabilitation centers are located in urban areas that are not easily reached by disabled people because of their geographic and cultural distance from urban areas (Barnartt 1992; Groce 1998).

Another question is whether to employ a “specialized services” approach or to incorporate rehabilitation into more general education and social service programs. There are different approaches and mixes of approaches, used in both developing and developed countries. Belgium, Finland, and France, for example, all provide vocational guidance in “ordinary” programs, although Finland provides specialized services for persons with severe disabilities (International Labour Conference 1998:25). Many scholars and activists, however, claim that establishing special services for disabled people is a flawed approach in that it perpetuates the stigma attached to disability and provides an excuse for mainstream programs not to make the adaptations necessary to provide services and activities to every citizen (Schriner, Rumrill, and Parlin 1995).

Genderis another important concern. Women with disabilities in developing and developed countries have different experiences with rehabilitation. When cultural practices discourage or prevent women from traveling by themselves or living without male supervision and protection, they are less likely to access rehabilitation services (Groce 1998).

More fundamental to the analysis of international rehabilitation is the general critique of professionalism. Expressed persuasively by scholars such as John McKnight (1995) and Ivan Illich (1976, 1987), part of this critique focuses on the possible (and actual) iatrogenic effects of professions’ helping behavior—effects that may occur at both the individual and societal levels. One source of iatrogenic effects is an overemphasis on the individual as the source (and solution) of the “disability problem.” Professionals engage in clinical reasoning, which, as Stone (1993) warns,

profoundly changes the way social problems are defined, the political instruments used to resolve them, and the relative power of social groups … [Clinical reason] accords with the liberal tradition of justifying differences in status and rewards by differences in individual achievement, merit, and even need. Clinical reason seems to give an independent source of knowledge to social and political authorities, rendering them less vulnerable to the (manipulative) desires of individuals. (P. 64)

This emphasis on individual-level change is caused, in part, by the training professionals receive, which tends to focus on disability as a characteristic of individuals and overstates the importance of diagnostic testing and assessment procedures. A case in point are the licensing criteria of the U.S. National Council on Rehabilitation Education that require no training in community development, systems consulting, or other strategies that have proved useful in furthering social change. This individual focus is a politically conservative approach to disability—one that first stops short of confronting and challenging the structural and attitudinal barriers that keep disabled people and other disadvantaged groups from being fully integrated into society and, second, attracts budding professionals who are more interested in producing individual change than social change.

The clinical approach is reinforced by the state’s role in funding training programs for rehabilitation professionals and employing them. The result is “profoundly antidemocratic”; by transforming social problems into “clinical syndromes,” the state

elevates a particular type of expert knowledge and denigrates or even ignores the knowledge, perceptions, and interpretations of ordinary citizens in their relationships with other individuals and with social institutions…. Ultimately, the most profound consequence of the rise of clinical authority is that it disguises or displaces conflict in the first place. Once a situation is defined as a matter of health and disease, or normality and pathology, both the problem and its treatment appear to be dictated by nature and no longer a matter of value choice and political resolution. (Stone 1993:65)

In addition to these concerns, a practical matter with serious implications for the future of rehabilitation is the fact that very few individuals with disabilities participate in rehabilitation programs. Helender (1993, cited in Groce 1998:182) estimates that only about 3 percent of people with disabilities receive services from such programs, an estimate that is roughly consistent with the 2 percent figure cited for “conventional rehabilitation centers” in Zimbabwe (Devlieger 1998:26) and the 7 percent figure cited by the U.S. General Accounting Office (1993). It seems safe to say that rehabilitation services would not be funded at levels necessary to expand services to the entire eligible population.

Given this critique of rehabilitation services, the time is ripe for a thorough evaluation of rehabilitation theory and practice, as well as the possibility for a transformative rehabilitation practice that focuses on the societal conditions that create disadvantage for people whose individual characteristics are outside the societal norm. In the subsequent sections, we will draw the outlines of such an approach and discuss its advantages. We will also suggest some broad measures for evaluating a transformative rehabilitation practice and briefly acknowledge the obstacles to its development.

What Should a Transformative Rehabilitation Practice Be?

The most important question is the following: What should a new transformative “rehabilitation” practice be? This is the central query arising from this many-faceted debate about employment issues and the traditional rehabilitation profession that is supposed to address them. Traditional programs, especially in developed countries, seem to exist in isolation from basic institutional structures such as families, neighborhoods, employers, religious groups, and other voluntary associations. Professionals are housed in offices, are largely invisible in their communities, and spend little time consulting with employers or other community members and institutions about making accommodations or improving attitudes toward people with disabilities.

Table 28.1 A Comparison of Traditional Rehabilitation Profession and Transformative Rehabilitation Practice

Traditional Rehabilitation Profession Transformative Rehabilitation Practice
Construct of disability Disability as an individual phenomenon. Recognizes role of discrimination but falls short of critical analysis of societal structures and practices. Assumes that social structures and practices produce disability from impairment. Uses systems-level interventions to address disabling conditions.
Target of intervention Primarily individual, with limited emphasis on families, schools, and employers. One person at a time. Community; social and political systems; attitudes.
Purpose of intervention To increase levels of individual functioning. To produce fundamental change in social, economic, and political structures.
Intervention strategies Training, education, and support of person with a disability. Limited consultation with employers. Almost always focused on accommodating one individual. Systems analysis and consultation, inclusive community and economic development, political action. Practitioner works with elected officials, educators, community planners and activists, employers, and so on.
Disciplinary traditions Medicine, psychology, education. Community development, political science, sociology, economics.

Instead, professionals confer with one-after-another “consumer” and a generally small number of community providers from whom services are purchased.

At the societal level, professionals rarely engage in the larger political dialogue regarding the status of people with disabilities. While professionals may take part in political debates to protect professional turf or integrity, they are less likely to weigh in on the side of creating fundamental changes in the political and economic relations of a society.

Thus, the professional dominance in disability policy is costly, has iatrogenic effects, and is incompatible with fundamental social change. If we believe that society itself is, metaphorically speaking, throwing disabled people into the river of unemployment, then why are we picking them out of the river one at a time rather than running upstream to stop them from being thrown in in the first place?

A new transformative rehabilitation would involve societal and community-level efforts to make the built and attitudinal environment more hospitable to disabled people. Although this is, obviously, a much different usage of the word rehabilitation than has historically been the case, it may be an appropriate application in that it denotes the remaking of society. Furthermore, the term rehabilitation profession is replaced by the term rehabilitation practice in the hope of overcoming the artificial elevation of expert knowledge over the knowledge possessed by ordinary people (see Table 28.1 for a comparison of the traditional rehabilitation profession with a transformative rehabilitation practice).

The “What” of Transformative Rehabilitation Practice. Professional knowledge about the individual-level aspects of disability should not be the only strategy—or even the primary strategy—in a transformative rehabilitation tool chest. Fundamental social change is the key to the doors of acceptance and opportunity that must be opened for disabled people. Fundamental change is necessary to transform the social, economic, and political structures of a society so that disabled people are viewed as normal and offered parallel opportunities to influence and benefit from those systems. This change must occur at all levels of a society, from the loftiest centers of political and economic power to the relations between and within families, workplaces, and neighborhoods. To produce such reforms, we propose that a transformative rehabilitation practice take what is known about the individual aspects of impairment and disability and apply this perspective within the context of a social change strategy. This transformation would permit the application of this knowledge to the situations of many more disabled people than can be helped by any number of traditional rehabilitation professionals.

The most promising possibility for meaningful progress, then, would be to move toward the development and implementation of a transformative rehabilitation practice. By this, we mean a rehabilitation practice that would focus on producing fundamental social change—and would measure its success in those terms—rather than focusing on the individual and individual-level change. The practice of rehabilitation would become driven by the circumstances of the society (not the individual), would recognize and take advantage of the strengths of the society, and would work throughout the society to address the needs and concerns of disabled people. In short, the society would become the unit of analysis rather than the individual.

The implications of taking such an approach are significant to the extent that the CBR approach has recognized the strengths of the community and the potential of the community to solve the problems experienced by disabled people. It has anticipated this “transformative rehabilitation.” What is now required is a transformation of the conversation. Rather than beginning with the needs of the individual and going from there to the community-based changes that are required to accommodate that individual, let us begin by asking how accommodating the society is—at all levels and in all areas—and go from there to the individual implications of societal-level change to improve its accommodative stance.

This conversation willbe basedon a thorough understanding of how societies work and how they may be worked with. It will be grounded in theories of power and influence, community and social change, and economic and community development. The inquiry will focus on the structural characteristics of the society, the attitudinal features of the society, and the components of the society that can be called into action through the promotion of enlightened, indigenous leadership with whom a rehabilitation practitioner consults and produces change. The activities of the rehabilitation practitioner will be focused on the society. The practitioner will apply knowledge about systems, social change, culture, and community to the problem of moving the society as a whole from where it is to where it might be. The rehabilitation profession is remade into a social change process founded in hope and faith.

This transformative rehabilitation practice also makes use of the tremendous amount of knowledge we have acquired concerning the adaptations that maybe made in society to accommodate individual differences. The rehabilitation practitioner will know what accommodations are required and how to promote a more accommodative stance in political, economic, and social structures at all levels. Policymakers, educators, business owners, and leaders of voluntary associations will have access to the practitioner’s knowledge about these strategies.

However, there are notable differences between the traditional rehabilitation profession and this transformative rehabilitation practice. A transformative rehabilitation practice would be grounded in a substantially different theoretical understanding than is the traditional rehabilitation profession. The primary theoretical orientation would be derived from those fields that are systems—and change—oriented, such as political science, sociology, community psychology, community and economic development, and systems theory. These theories would permit practitioners to adopt a conceptual framework that is more consistent with the widely recognized need to produce societal-level change.

Thus, the practitioner’s primary mode of operation would be dictated not by an individual-by-individual analysis of problems and solutions but rather by an analysis of the societal systems through which fundamental change may be achieved to improve the accommodation and acceptance of disabled people. When analysis verifies that parts of the political or economic structures are inaccessible, the practitioner may support people with disabilities as they together engage the larger systemin a change process. The outcomes of this approach would most certainly affect individuals with disabilities, and those effects will be direct and observable. However, the practitioner’s work will begin not with the individual (indeed, practitioners may not even know the eventual beneficiaries of their work) but with the society as a whole and with its discrete parts. The practitioner’s efforts would involve working with policymakers, the private sector, and other institutions and actors to ensure that barriers are systematically addressed and reduced.

The “Who” of a Transformative Rehabilitation Practice. A transformative rehabilitation practice will require a practitioner who is prepared to engage a wide range of individuals and groups operating in the political, economic, and social spheres. Such work will demand an understanding of power and economic relations, the ability to identify and establish collaborations with leaders in those spheres, and a sophisticated approach to supporting and promoting the change process.

This reinterpretation of the rehabilitation process and its reassignment to the societal level offers a greater opportunity to empower people with disabilities than does the weakened version of empowerment envisioned by the traditional rehabilitation profession. In the weakened version, power must be wrested away from the professional (or granted by the professional) and is typically thought of as a characteristic of the individual that does not depend on—and, in fact, is irrespective of—objective conditions of power in the social, economic, and political spheres. Empowerment used in this way is almost a misnomer. In the alternative model of transformative rehabilitation practice, empowerment is a natural by-product of the process, although it occurs not because of professional intervention with disabled individuals but rather because of intervention at the societal level. Through transforming the systems of society, the objective conditions in which disabled people live may also be transformed, resulting in true empowerment for the individual who has a disability. Empowerment results not from the benevolence of a professional but from change in the attitudinal and built structures of the society in which the disabled person lives.

Transformative rehabilitation practice will focus on change in the political, economic, and social spheres of society. Because of space limitations, it is impossible to address in any great detail what this practice would look like in each of these spheres or what would be the results of such a practice. However, we will touch on a few general themes in the context of the political and economic spheres.

Transformative Rehabilitation Practice in the Political Sphere

Practitioners of transformative rehabilitation and their allies will naturally want to focus on political issues. These may include the development or reform of policies affecting people with disabilities, the representation of disabled people in elected governments, or any myriad other political concerns. This connection to the political sphere is one that is largely overlooked in the traditional theories and profession of rehabilitation and sorely deserves attention. In the United States, for example, rehabilitation training programs focus almost exclusively on individual-level phenomena, and thus a traditional rehabilitation professional is ill equipped to analyze or affect the political process. This is a startling omission given the widespread acknowledgment that politics plays a significant role in the quality of life of disabled people.

A transformative rehabilitation practitioner will have the theoretical understanding of political issues required to act strategically within the political system to produce fundamental change. For example, when candidates and political parties within a representative democracy fail to address the concerns of disabled people accurately or adequately, the practitioner and his or her partners (which would include local disability groups or other indigenous partners) may conduct voter education campaigns, which provide information to the disability community about candidates’ positions on disability issues, thus producing more well-informed voters and more attentive candidates. Similarly, if U.S. courts were to misinterpret the Americans with Disabilities Act’s definition of a covered individual (thereby restricting the breadth of coverage), the transformative rehabilitation practitioner might assist in crafting remedying legislation. Or, the transformative rehabilitation practitioner might promote the adoption of treaties banning the use of land mines and participate in negotiations to improve working conditions for all disadvantaged groups.

This proposed political role for the rehabilitation practitioner is reminiscent of the systemslevel advocacy often engaged in by centers for independent living in the United States. The infusion of an overtly political focus into a transformative rehabilitation practice acknowledges and emphasizes the significance of public policy in the lives of disabled individuals. The traditions of rehabilitation theory and professionalism have ignored the dynamics of the policymaking process at the peril of persons with disabilities, and the inclusion of policymaking issues here is designed to remedy this omission.

Transformative Rehabilitation Practice in Community and Economic Development

A vital part of a transformative rehabilitation practice is the purposeful integration with broader community and economic development activities. Efforts in this direction are already a strong focus in the developing world (see Harper and Momm 1989; Metts and Metts 1996), where so many decisions about resource allocation are driven by economic development needs but should also be a focus in the developed world as well.

An illustration of the way rehabilitation services can be part of a larger economic development effort is the example of microenterprise programs. Established first in Bangladesh, the microenterprise movement began with the provision of small loans to poor individuals (many of whom were women) who had almost no access to banks or other traditional sources of capital. The first such programs established small lending groups that were given a relatively small pool of money from which to make loans to group members. Group members worked with staff to develop individual business plans, and then groups made the decision to loan money to individuals when those individuals had demonstrated that they had taken the necessary steps to succeed in their businesses. These programs have been established in some locales in the United States and are showing considerable promise (Metts and Metts 1996).

Self-employment can also occur outside of a microenterprise program, of course. Harper and Momm (1989) describe the experiences of more than 50 disabled entrepreneurs in Gambia, India, Indonesia, Kenya, the Philippines, and Zimbabwe and argue that self-employment may have the “potential for remoulding traditional rehabilitation approaches, at least in developing countries” (p. 5), because of the nature of the economies there. While self-employment would not be an appropriate choice for every individual with a disability, it should not be dismissed as an option.

A critical characteristic of the self-employment model is its contribution to economic and community development. In general, these enterprises are small and require little capital investment, perhaps only a basket in which to display goods for sale. There is typically little infrastructure required because the entrepreneurs use the roadsides or public urban spaces for their activities. These small businesses are labor intensive, and unused labor is common. Self-employed people often operate in their own communities, thus making little demand on limited transportation capacity. They tend to produce goods that poor people need and can afford to purchase (Harper and Momm 1989).

Self-employment, defined broadly as including not only small business but also larger enterprises owned by one or more disabled individuals, has another significant advantage. It provides a true economic stake for people with disabilities, one that will inevitably lead to empowerment in both the economic and political spheres. In this respect, self-employment (though still largely an individual-level effort) is consistent with a transformative rehabilitation practice by emphasizing the importance of ownership of economic resources. When the numbers of disabled business owners reach some critical mass, it is at least possible that they will become a political power base within their communities or larger society.

Evaluating a Transformative Rehabilitation Practice

Evaluating the effectiveness of a transformative rehabilitation practice (and other aspects of disability policy such as income maintenance and health care programs) is a pressing concern. Perhaps because of its colonial past, writers from Africa seem especially sensitive to the need to evaluate such efforts in terms of fundamental social change. David Werner (1995), for example, states that

the long-term value of any rehabilitation or development effort must be evaluated in terms of how much it empowers marginalised groups and moves us toward fairer, more fully democratic social structures. (P. 25)

Thus, a significant emphasis in the evaluation process should be the degree to which oppressive conditions for all people with disabilities are relieved in all spheres of society. While it is by no means clear how such achievements would be measured, it does seem reasonable to suggest that broad measures of political, economic, and social equality might be identified and used to evaluate the effectiveness of a transformative rehabilitation practice.

The circumstances of minority individuals with disabilities and women with disabilities must be given significant attention in evaluating such efforts. Inquiries that are limited to simple demographic and outcome measures at the program level (e.g., the number of minorities and women who participate, the kinds of disabling conditions they have, the services they receive, and their employment outcomes) are myopic. Evaluating a transformative rehabilitation practice will require attention to the systemic exclusionary policies and environmental and attitudinal barriers that have kept minorities of all kinds in marginalized circumstances. A transformative rehabilitation practice must cast a wide net with respect both to the strategies employed and the outcomes to be achieved.

Making Change: The Challenges of Politics and Culture

Creating a transformative rehabilitation practice will require overcoming several major challenges. First among these are the institutions and practices they engage in to develop and run traditional rehabilitation programs around the world. In the developed nations, these take the form of well-established professions whose position and role in society are generally supported by both politicians and the general public. In the majority world,

There is an enormous industry based on disability, in which charitable institutions vie with “community-based programmes” for major funding; vested interests are well entrenched among rehabilitation professionals; [and] UN agencies and NGOs debate disability at their conferences. (Coleridge 1993:5)

The habits of professionals and their supporters will be difficult to change, but it is by no means impossible.

A related problem is that rehabilitation programs are controlled by nondisabled individuals, who, according to Coleridge (1993), dislike the “militancy exhibited by disabled people—who, it is assumed, should keep quiet and accept their situation as unfortunate but unchangeable” (p. 5). The disability rights movement must be an integral part—indeed, the foundation—of change efforts. Because it is fundamentally about changing the social construction of disability, the movement has the intellectual prowess to analyze the impairment-environment interaction from the basis of its members’ personal experience and to apply this analysis to the question of a new paradigm for rehabilitation.

The disability rights movement is actively engaged in developing the breadth of leadership necessary to enunciate all variations of the impairment-environment interaction. The movement continues to focus on improving its capability to attract and represent the interests of women with disabilities, minority individuals with disabilities, and other parts of the disability community whose experiences and concerns historically have not found expression in the movement. Because disability organizations historically have been headed by men and have concentrated on men’s issues, women’s experiences and interests have not been fully explicated or represented in the movement’s agenda. Recent advances, made through the efforts of the United Nations International Decade, Rehabilitation International, the World Institute on Disability, Mobility International USA, and other national and international organizations promise to remedy this situation, but much more work is necessary.

Conclusion

In this chapter, we have evaluated the conditions in which people with disabilities live and have argued that the economic status of people with disabilities is intimately connected to a nation’s ability to accommodate and value individual differences. Furthermore, we have suggested that many current policies and practices—particularly traditional rehabilitation theories and professions—have the unintended consequence of impeding the fundamental social change that appears necessary to produce true empowerment for disabled people. We have proposed that a new approach, which we call transformative rehabilitation practice, be taken to address the societal-level conditions that act as barriers to true equality for disabled individuals, and we have briefly described examples of how such practice might work in the context of the political and economic spheres. We have also recognized that there are many impediments to the establishment of this new transformative rehabilitation practice.

Given the continuing disadvantaged status of individuals with disabilities, it seems apparent that programs and policies targeted to employment concerns are in need of a critical reexamination, which asks the most basic questions about the level of analysis and intervention for such efforts. Why is it that we continue to operate primarily at the individual level of analysis and intervention, even when the evidence continues to indicate that people with some kinds of difference are disabled by societal-level policies and practices? Why do we persist in emphasizing the evaluation and labeling the individual—as well as the provision of specialized treatment, education, and training to the disabled individual—despite the continued resistance of mainstream settings that could and should provide such supports and services as part of their routine functioning? Perhaps the answer lies in the continued reliance on theories and professions that operate from the perspective of the individual to the almost complete exclusion of the society. We would propose that individual differences could be accommodated and valued only when societies themselves change. This is hardly a new observation, but the application of this perspective to a transformation of the rehabilitation profession may be.

In many countries, attitudes and policies have relegated disabled people to the margins of the economy. The steps taken to remedy this isolation and stigma are usually politically conservative measures that, often inadvertently, contribute to the continued disadvantage of disabled people by identifying their differences and issues as “special” and “unique.” Traditional rehabilitation theories and professions are such strategies. By labeling disabled people as different, abnormal, and wanting—albeit deserving—the rehabilitation profession and its intellectual justifications largely ignore the many ways the attitudinal and built environment identifies and devalues the forms of individual difference called disability.

The development and implementation of a transformative rehabilitation practice will require different emphases in research and policy. With respect to the research agenda regarding employment issues, we will need to expand our attention to questions about the structure of economies and their consequences for the production and management of individual difference. We will need to ask more questions about the creation and use of technologies to expand opportunities for disabled people, and these inquiries will need to include examination of the resource flow between developed and developing nations. Other research efforts consistent with a societal-level analytical and intervention strategy include, for example, comparative analysis of strategies for enforcing antidiscrimination measures in the workplace. It also includes evaluation of political efforts taken to reduce the presence of land mines around the world; the development and validation of measures for evaluating change in political, economic, and social systems; and the evaluation of methods for engaging advocacy groups in producing such change.

Social policy may also require reform. One can imagine (though not necessarily predict), for example, the rewriting of the U.S. Rehabilitation Act to “turn it on its head” and create a federal-state partnership for producing fundamental social change. The act might define its purpose in terms of creating such change and might fund transformative rehabilitation practitioners to analyze societal conditions and forge relationships with local, state, and national groups to improve the accessibility of society at all levels and in all respects. Funded activities might include working with local governments to ensure the accessibility of housing and transportation, investigating claims that local banks discriminate against disabled business loan applicants, promoting parity for mental health treatment in health insurance plans, and advocating with the state chamber of commerce to require that its members commit to hiring more disabled people. Practitioners might be evaluated on the amount and effectiveness of such engagements. Agency ombudsmen might be employed to ensure that such evaluations are not affected by the influence of economic and political entities.

These are but a few thoughts on the research and policy implications of our musings about a transformative rehabilitation practice. Further consideration of the many issues and questions surrounding the future of employment-related programs, policies, and practices should involve the entire international disability community. We conclude this chapter by emphasizing that it is possible to create new programs and policies that are culturally competent and that contribute to economic and social justice. This imperative creates a powerful claim on the world’s intellectual and political resources. Disabled people and those who live with and care about them can shape a changing universe to make it more accepting and accommodating to people whose individual differences have historically been marginalized and stigmatized. To do so will take courage, creativity, and great perseverance, but the potential benefits are so significant that we must accept the challenge.