Women and disability: exploring the interface of multiple disadvantage

Abstract

In general, women with disabilities are more discriminated against and disadvantaged than men with disabilities. In the industrialised countries there are consistent, although not necessarily large, gender differences in income, employment and education for people with disabilities. Poverty and deprivation magnify these inequalities, and can determine access to food, care and social inclusion, and even threaten survival. Women with disabilities are also at greater risk of physical, mental and sexual abuse, and because of stigmatisation have lower marriage prospects. There are more barriers to access and participation for women than for men, and mothers and caregivers in particular face enormous challenges when raising children with disabilities or chronic illnesses, especially within the context of women-headed households and early pregnancy. This article emphasises the need to approach disability as an integral part of development rather than as a separate need competing with other causes and manifestations of poverty.

1. INTRODUCTION

In 1992 Bonnie Sherr, a Canadian film-maker who suffered a stroke which left her disabled and wheelchair bound, wrote that she felt abandoned by feminism. ‘There is clearly a conflict between feminism's rhetoric of inclusion and failure to include disability,’ she stated (cited in Abu-Habib, 1997: 1). Historically, both disability studies and gender scholars have neglected women with disabilities and, as Traustadottir (1990: 1) has pointed out, ‘almost all research on people with disabilities has assumed the irrelevance of gender as well as other social dimensions such as social class, race, ethnicity, and sexual orientation’. More recently Pokempner and Roberts made a similar point, arguing that while in the last decade the relationship between poverty and disability has been widely acknowledged, less attention has been devoted to the extent to which ‘disability and illness are distributed in ways that reflect gender, racial, and economic inequalities’ (2001). While there is a substantial literature on disability, and disability groups all over the world have made considerable progress in promoting issues in disability, women with disabilities have not been integrated to any significant extent into either the disability movement or the women's movement (see, for example, Traustadottir, 1990; Pokempner & Roberts, 2001; Harriss-White, 2003).

This article explores the interface between disability and gender, particularly within the context of poverty, and argues that awareness of the cumulative impacts of social disadvantages is essential to a full understanding of poverty in its various dimensions, and of the impacts of disability and impairments on impoverished people. First, the article reviews some of the data on women with disabilities in the United States and other industrialised countries, where existing data are most comprehensive. This section, which looks at various trends in employment, income, education, welfare benefits and so on, draws heavily on the comprehensive statistics of the Chartbook on Women and Disability in the United States compiled by Lita Jans and Susan Stoddard (1999), of the National Institute on Disability and Rehabilitation Research.

Secondly, the article locates disability within the context of other social inequalities and disadvantages such as poverty, race and family structure. The complex interconnection of issues such as these have implications not only for families or households in general, but also for women in particular. The role of disability and gender is then considered within the context of developing countries, where conditions such as pervasive poverty, lack of services, and limited recognition of women's rights have profound implications for both women and people with disabilities. The article concludes with a discussion of the implications of the links between disability, gender and poverty, and argues for the need to include disability as an integral part of development rather than as a separate need competing with other causes and manifestations of poverty.

Before proceeding, it is necessary to establish what we mean by the term ‘disability’, and in particular to distinguish between two basic approaches to disability that are now commonly known as the ‘medical model’ and the ‘social model’ of disability. In common with most popular conceptions of disability, the medical model views disability as a health condition of the individual that is directly caused by disease or trauma. Addressing disability therefore primarily requires medical care and/or the individual's adjustment and behaviour change. The social model, on the other hand, sees disability mainly as a socially created problem. Disability is not seen as an attribute of the individual, but rather as ‘a complex collection of conditions, many of which are created by the social environment’. Addressing disability therefore requires social action aimed at integrating people with disabilities into society and modifying the environment to support their full participation in all areas of social life (WHO, 2001). In keeping with the social model, Albert et al. define disability as ‘a complex system of social restrictions imposed on people with impairments by a highly discriminatory society’. They argue that: ‘Disability, therefore, is a concept distinct from any particular medical condition. It is a social construct that varies across culture and through time, in the same way as, for example, gender, class or caste… In this sense, disability as a policy issue becomes a cross-cutting social one, rather than something primarily associated with health and individual well-being’ (2002: 16).

In exploring the relationship between disability and gender, the social model is particularly helpful in focusing our attention on those aspects of disability that emphasise the commonality of disability and gender, rather than on the medical condition or impairment that has relegated disability to the specialised, and depoliticised, realm of medicine. However, in spite of recognition of the social model in many parts of the world, and especially in the United Kingdom, much confusion exists in the use of the term ‘disability’, and many writers (particularly those addressing issues of poverty and disability) tend to use it to refer to impairments rather than the social restrictions imposed on people with impairments. In this article, therefore, we argue that both disability (as a social process) and impairments create disadvantage and poverty and that, although it is often difficult to disentangle the impacts of disability from impairment, both elements need to be taken into account in getting to grips with the relationship between disability, poverty and gender. Although we try, where possible, to distinguish between disability as a product of discrimination and the impairments and activity limitations upon which this discrimination is based, the terms ‘disability’ and ‘people with disability’ are used in this article to refer to both impairments and the social discrimination that accompanies impairments.

2. DISABILITY AND WOMEN IN THE INDUSTRIALISED COUNTRIES

In the industrialised countries, data show that women with disabilities are, in general, more disadvantaged than men with disabilities, with indicators for income, education, employment and social assistance showing consistent, although not always large, gender differences. Data from the early 1980s, for example, showed that men with disabilities were almost twice as likely to be employed as women with disabilities, while women with disabilities in full-time jobs earned only 56 per cent of what men with disabilities in full time jobs earned (Elwan, 1999: 28).

More recent data also show that women with disabilities face a double disadvantage in the workplace based on both their gender and their disability status. Women with disabilities are not only less likely to be employed, they also earn less than men (Jans & Stoddard, 1999: 17). The dual disadvantages of gender and disability are illustrated in Figure 1. The figure clearly shows that women have lower rates of participation in the labour market whether or not they have a disability. The presence of a disability has an impact on the employment of both women and men, with the severity of the disability having the greatest impact. It is also clear that, especially in relation to severe disabilities, the impacts of gender and disability are cumulative.

Figure 1: Percentage of US population aged 21–64 years employed by gender and disability status (1994–95)

Similar trends in relation to income are illustrated in Figure 2. In 1994–95, working women between the ages of 21 and 64 earned less than working men, whether or not they had a disability. Women with disabilities also earned less than women without disabilities, and less than men with disabilities. Men without a disability earned 49 per cent more than women without disabilities. Among people with a non-severe (or mild) disability, men earned 55 per cent more than women. In the case of severe disability the gender gap was smaller, with men earning 26 per cent more than women, although for both men and women the gap between those with mild and severe disabilities was substantial. However, in spite of this large gap, it is interesting that the median earnings of men with severe disabilities were still slightly above those of women with mild disabilities.

Figure 2: Median monthly earnings, by disability status and gender, aged 21–64 years, 1994–95

Gender inequalities are also evident in relation to education for children with disabilities. While males and females were equally represented in the school-age population, this was not the case with special education. In fact, boys made up about two-thirds of students in special education, with the greatest discrepancies occurring in learning disabilities (74 per cent boys) and emotional disturbances (76 per cent boys). On the other hand, girls in special education scored lower on IQ tests, and were reported to have disabilities at earlier ages. A further point of interest is that girls in special education tended to do better academically than their male counterparts. However, on completing their education, girls were (as we have seen) less likely to be employed, earned lower wages, and were also less likely to enrol for post-secondary education.

Inequalities also exist in relation to social assistance in the United States. As the primary programme of federal benefits for children with disabilities and their families, Supplemental Security Income (SSI) is biased in favour of boys. In 1998, for example, 63.5 per cent of children awarded SSI grants were boys, while 36.5 per cent were girls. Between 1988 and 1998, boys were consistently awarded more SSI grants than girls. In fact, as shown in Figure 3, as the number of grants has increased, the gap between male and female beneficiaries of the grant has also increased. While it is necessary to take into account that boys in the US have higher rates of disability than girls, as Jans and Stoddard point out, ‘this alone does not account for the gap in SSI benefits between boys and girls’ (1999: 16).

Figure 3: Number (in thousands) of children with disabilities (aged 0–17 years) receiving Supplemental Security Income (SSI) grants

Welfare benefits also differ among adults. In 1995, for example, 25.6 per cent of women and 30.6 per cent of men with work disabilities received Social Security benefits. On the other hand, women received higher percentages of need based benefits such as food stamps (29.1 per cent of women, 19.8 per cent of men), Medicaid benefits (36.2 per cent of women, 27.2 per cent of men), public housing (6.8 per cent of women, 4.4 per cent of men) and subsidised housing (4.6 per cent of women, 2.7 per cent of men). Gender differences were also apparent in social security benefits for workers with a disability, with more men than women receiving OASDI (Old Age, Survivors and Disability Insurance) benefits, as well as the average grant for men being higher than that for women. In 1997, for example, 59 per cent of those receiving benefits were men. At the same time, the average monthly benefit for men in 1997 was $810, while for women it was only $595. Perhaps most disturbing is that benefits have been consistently higher for men over four decades, and that the gap between average monthly grants to men and women has grown since the 1970s (see Figure 4, below).

Figure 4: Average monthly OASDI grants for disabled workers by gender 1960–95

Another benefit provided for people with disabilities in the United States is the Vocational Rehabilitation programme, which helps people with disabilities obtain employment. In 1996 the programme served more than 1.2 million people, of whom more than three-quarters were people with severe disabilities. In that year, women represented only 43.9 per cent of the 589 472 cases closed.

Data collected in 1987 and updated to 1993 showed that the medical expenditure of people with disabilities was four times greater than that of people with no disabilities [in this case disability was defined as an activity limitation in a major life area such as work, school or housework, due to a chronic health condition or impairment]. The study also showed that males with disabilities had higher per capita expenditure than females with disabilities in all age groups except children. These differences were particularly pronounced for the 45–64 age group, where per capita expenditure on men ($6100) was 40 per cent higher than on women ($4365).

Against this background, it is not surprising that women are more likely to be living in poverty than men, and that people with a work disability are more likely to be living below the poverty line than those with no work disability. In 1992, it was estimated that for people with work disabilities in the 16–64 age group, 33.8 per cent of women as against 24.2 per cent of men were living in poverty. [Work disabilities were determined by survey questions that asked respondents whether they had a condition that limited the kind or amount of work they could do. In 1998, for example, 17.2 million people, or 9.9 per cent of the working age US population (16–64 years) had a work disability.] For those classified as having a severe work disability (a condition that prevented them from working), 40.5 per cent of women compared to 31.2 per cent of men were poor. Figure 5 clearly demonstrates the cumulative impact of disability and gender on poverty. The data show not only that having a work disability has a dramatic impact on poverty for both men and women, but also that gender inequality contributes to very high rates of poverty among women with work disabilities.

Figure 5: Percentage of people (aged 16–64 years) living in poverty by work disability status and gender

Similar trends have been shown to exist in Canada. For example, according to 1991 statistics provided by Barile (2002) the unemployment rate among women with disabilities in Canada was 16 per cent compared to 13.2 per cent for men with disabilities and 9.9 per cent for women with disabilities. Similarly, poverty among women with disabilities was 25.1 per cent compared to 18 per cent for men with disabilities and 21 per cent for non-disabled women. It is of interest that the poverty rate of women without disabilities was higher than the poverty rate of men with disabilities. Barile also cites a 1999 study by Doe and Kimpson which showed that women who became disabled received fewer disability pensions than men, that part-time work for those on disability pensions was more limited for women than for men, and that in general women received fewer retirement pensions than men.

To sum up, the data presented above show that disability (largely defined in terms of impairment or chronic illness) has had a consistent, and in some cases severe, impact on the lives of both men and women in North America. However, the negative impact of disability is unevenly spread between the genders. While in some cases the differences between men and women might be relatively small, especially when considered against the background of the overall impact of disability, it is clear that women bear a heavier burden than men, and that these inequalities are systematic.

3. DISABILITY AND GENDER WITHIN THE CONTEXT OF OTHER DISADVANTAGES

While the systematic relationship between disability and gender in the foregoing analysis is of some importance, it takes no account of other disadvantages and inequalities that might have some bearing on the dual disadvantage of disability and gender. For example, even a small difference in income is going to have a greater impact on a poor household than on an affluent one. The structure of households also plays a role. For example, a household of two people who are earning incomes, one of whom has a disability, is less vulnerable than a household of only one income earner who has a disability. Clearly, also, the more children or dependants one adds to the equation, the more vulnerable the household becomes, and the greater the impact of social inequalities associated with gender and disability. The situation may also be further complicated by other disadvantages and inequalities such as race.

The interconnections between poverty, race and disability have profound implications not only for households in general but more specifically for women. As Pokempner and Roberts (2001) have argued, the overlap of disability, poverty and race in the United States is significantly affected by family structure and gender inequalities. Women are especially vulnerable not only because of their weak positions within labour markets, but also because within the highly skewed distribution of domestic labour most of the responsibility for parenting and caregiving falls on them. This vulnerability is intensified when women have to care for one or more children with disabilities:

Their return in the waged labor market is rarely sufficient to support a family and the work done to care for their family is not valued or compensated. The devaluation of both types of work creates additional costs for the mother attempting to care for a disabled child. These additional costs highlight the gender inequalities which continue to pervade the labor market in terms of wage structures, the devaluation of caregiving work inside and outside the home and the ill-fit between family caregiving and work within the market. (Pokempner & Roberts, 2001)

People with disabilities and their families are often burdened by additional costs resulting from disability. Such costs include special medical care, rehabilitative and restorative equipment and services, providing for special education needs, and costs incurred for or by care providers, including opportunity costs of foregone income. As we have already seen, such costs can be considerable, with medical costs alone being up to four times greater than those of people without disabilities. There are also various costs associated with marginalisation or exclusion from services and social and community activities. For example, public transport often does not cater for the needs of people with disabilities, thus restricting their mobility and compelling them to use more expensive alternatives such as taxis or private transport.

Lukemeyer et al. (2000) studied the impact of caring for children with disabilities and chronic illnesses on poor families in the United States, and found that both out-of-pocket expenses and foregone earnings represented a substantial burden for many of the families studied. Using a sample of low-income families in California, the study found that almost half those families with special needs children had incurred some direct, out-of-pocket expenses in the preceding month, and about 20 per cent incurred costs of more than $100. Half the mothers with disabled children indicated that caring for the child made it difficult to work and 19 per cent reported that special care responsibilities prevented them from working at all. Based on their data, the writers estimated an average loss of about $80.52 per month in mothers' foregone income for each household with a severely disabled child. They conclude that families with exceptional children are at ‘exceptional risk for economic hardship, due to heightened demands on family resources and to reduced availability for employment’ (Lukemeyer et al., 2000: 412).

The problem of costs associated with disability is compounded by family structures, particularly among the more impoverished sections of the community where single-parent families and women-headed households predominate. Since the 1960s the United States, in common with many other parts of the world, has witnessed a dramatic increase in female-headed households. For example, between 1960 and 1990 the percentage of all children who were living in mother-only families grew from 8 per cent to 20 per cent (Corcoran & Chaudry, 1997: 42). This trend and the strong association between female-headed households and poverty (for example, between 1959 and 1988, the percentage of poor children living in mother-only families rose from 20 per cent to 57 per cent) have prompted social commentators to talk about the ‘feminisation of poverty’ (Corcoran & Chaudry, 1997: 43; Pokempner & Roberts, 2001). Racial differences in family structure follow similar patterns. In the United States in 1992, for example, 59 per cent of African American children lived in female-headed families, in contrast to only 17 per cent of white children. [Similar conditions apply in South Africa. For example, the 1999 October Household Survey showed that 42 per cent of all African households (2.7 million) were female-headed (Aliber, 2003: 480). According to the South African Human Development Report for 2000 (UNDP, 2000), twice as many female-headed households (60 per cent) as male-headed households (31 per cent) were poor.]

The complex relationships between gender, race, poverty and disability need to be seen within the context of the dynamics of poverty and disability. Disability can be (and has been) seen as both a cause and a consequence of poverty. This is because disability increases the risk of poverty, while poverty creates the conditions for increased risk of disability. Poor people with disabilities may therefore be seen as caught in a vicious circle of poverty and disability (see, for example, Elwan, 1999; Burchardt, 2003; Emmett, 2005). Our discussion so far has focused mainly on the ways in which disability increases vulnerability to poverty; for example, because of the costs associated with disabilities, discrimination in the labour market, and difficulties in accessing education. However, poverty also increases vulnerability to disability through poor nutrition, lack of access to healthcare, greater exposure to violence and unintentional injuries, lack of knowledge of prevention, etc. (Elwan, 1999; DFID, 2000: 1; Yeo, 2001). The greater vulnerability of the poor to impairment and disability, whether through malnutrition, inadequate health care or violence, relates largely to environmental factors and disparities in economic, social and political power associated with being poor. For example, children who are raised in poverty are at increased risk of a wide range of health risks and outcomes. Poor children are more likely to be of low birth weight, to die in their first month of life and to grow up with chronic health problems, such as asthma and anaemia, because of the limited ability of their parents or caretakers to provide adequate nutrition, health care and housing, etc. Childhood poverty has also been associated with nutritional indicators of growth stunting and wasting. In general poor children are not only prone to poorer health than non-poor children, but are also at greater risk of accidents and injuries that can result in physical impairments that restrict their activities. Poor children are also more likely to spend more time in hospitals or in bed than children from more affluent backgrounds. Furthermore, low-income adolescents are more likely to become involved in risky and health compromising behaviours such as smoking or early sexual activity (Brooks-Gunn & Duncan, 1997: 58; Moore & Redd, 2002: 3).

For both children and adults, interactions between poverty, gender, race and disability produce complex patterns of social inequality and debilitation. For example, in the United States poverty and disability have been consistently related to race and gender. According to the 1994–95 Survey of Income Participation, for example, the proportion of people with a severe disability between the ages of 22 and 44 years was 11.8 per cent for African Americans, 5.6 per cent for whites and 6.7 per cent for Hispanics. For individuals aged 45–54, the percentages were 18.4, 10.5 and 15.7, respectively. African American children, who are twice as likely as white children to be poor, also experience illness and disability disproportionately. High rates of poverty among African Americans and other minorities only partly explain these higher rates of disability, because even when socio-economic status is controlled, the correlation between race and the risk of ill health and disability remains. Similar trends exist in relation to HIV/AIDS in the United States. In 1991, for example, African Americans were 3.5 times more likely to contract AIDS than whites. The risk was even higher among African American women, who were 13.8 times more likely to contract AIDS than white women (Pokempner & Roberts, 2001).

Since women disproportionately head poor families, they are at greater risk of suffering illness and disability than members of the general population, while at the same time they endure the negative consequences of disability. Furthermore, the problems of female-headed households are often linked to early or teenage pregnancies, which carry with them a range of other disadvantages such as:

• Dropping out of school in order to give birth to or care for a child

• Obstacles to continuing education after the birth of the child

• More limited prospects of marriage (this is not to suggest that marriage is necessarily advantageous to women under all circumstances, but rather to illustrate the ways in which disability can limit the choices open to women, and by extension to men)

• Where marriage does take place at a young age, the limited experience of the couple and the additional demands of parenthood often lead to the dissolution of the marriage

• Greater probability of low birth weight and giving birth to a disabled child.

The cumulative impact of disability, poverty and other social disadvantages such as gender, race, age and physical location can therefore create extreme vulnerability and exclusion for those sections of the population who suffer multiple and overlapping disadvantages.

4. DISABILITY, POVERTY AND GENDER IN DEVELOPING COUNTRIES

So far this article has focused exclusively on the relationship between disability and gender in the industrialised countries, particularly in the United States. The reason for this is that very few hard data exist on disability trends in the developing countries. The evidence that does exist is, for the most part, fragmented and often anecdotal. It does, however, suggest that in general trends in developing countries are very similar to those in industrialised countries, except that conditions in the developing countries are likely to be worse and considerably more prejudicial to people with disabilities and especially women with disabilities. This is likely to be the case for a variety of reasons, including higher rates of poverty and unemployment, pervasive deficits in services and social security, environmental and social conditions that are not conducive to health and political and cultural limitations on human (and especially women's) rights.

Against this background one would expect that prevalence rates for disabilities would be higher in the developing countries of the South than in the industrialised countries of the North. In terms of the data that do exist, however, this does not appear to be the case. While in the industrialised countries estimates of percentages of the population with impairments tend to be between 10 and 15 per cent, in the developing countries the figures tend to be significantly lower, usually below 6 per cent of the total population. Various reasons have been suggested for this discrepancy, including ‘premature death of disabled people (mainly infants, female children and women), failure to record disabled people in censuses and surveys, and higher “thresholds” for the identification of impairment and disability’ (Albert et al., 2002: 4).

A further aspect of the discrepancy in prevalence rates is that survey results generally show higher rates of disability for women in the industrialised countries, but lower rates in the developing ones. [For example, in 1995 in the United States it was estimated that women and girls made up 21.3 per cent of the total non-institutionalised population, as against 19.8 per cent for boys and men. This higher disability rate for women has been attributed to the higher average longevity of women (Jans & Stoddard, 1999).] Lower female rates may indicate that severe impairments may be male-dominated, or that females with disabilities may be under-reported or may receive less care and die sooner. For example, estimates from India and Pakistan indicate that male disability rates are higher than female rates. This ‘could indicate that girls and women with disabilities receive less care and support, and die earlier. Another possibility is that the gender division of labour is such that disabled women contributing to household activity are not identified as disabled, whereas the visibility of disabled men is greater’ (Elwan, 1999: 9). Studies conducted in Yemen and Egypt showed similar trends, with higher prevalence of disability among boys, which researchers attribute to higher mortality rates among girls with disabilities (Abu-Habib, 1997: 1–2).

The suggestion that lower rates of disability among women in developing countries may be related to higher mortality rates for women and girls in these countries receives some support from the demographic phenomenon of the ‘missing women’ that emerges from Amartya Sen's work on poverty and inequality. Using a range of demographic analyses, Sen (1999) showed unusually higher age-specific mortality rates for women in some developing countries, particularly those in South and West Asia, North Africa and China. Comparisons with male : female ratios in Europe, North America and sub-Saharan Africa show more than 100 million women ‘missing’ in selected countries in Asia and North Africa. Sen attributes these gender specific mortality rates directly to extreme gender inequality in these countries, and more specifically to ‘the comparative neglect of female health and nutrition, especially – but not exclusively – during childhood’ (1999: 106).

Although it is not clear to what extent disability plays a role in this horrific phenomenon, disparities in the disability rates of males and females in developing countries suggest that there may be a link, and that for at least some developing countries inequalities associated with gender and disability are a matter of life and death. One indication of the links between gender, disability and mortality relates to orphans and abandoned children in China. According to official figures for 1999, of 100 000–160 000 orphans and abandoned children, 90 per cent were girls and the majority of the remaining 10 per cent were boys with impairments (Chronic Poverty Research Centre, 2004: 22).

Other information available on women and girls with disabilities in developing countries provides further support. In some communities, for example, girls with disabilities receive less care and food, have less access to health care and rehabilitation services and may have reduced access to education and employment opportunities. Women with disabilities sometimes also have poorer marriage prospects than disabled men, and can be at risk of being physically and sexually abused. Abuse from individuals outside the family often goes unreported because of the shame that some families feel in having a daughter with a disability (Elwan, 1999: vi; DFID, 2000: 3). As pointed out in the South African Integrated National Disability Strategy (RSA, 1997), for example, ‘disabled women experience the same oppression as non-disabled women, but often without even the status that women traditionally receive as mothers or wives. In addition, disabled women experience more discrimination than other women from being unable to live up to the demanding ideals for womanhood imposed by society’.

Having a person with a disability in the family is sometimes thought to damage the marriage prospects of other members of the family. It is also suggested that men with disabilities are more likely to marry than women with disabilities. Abu-Habib maintains that ‘discrimination starts at home, in the early years of the life of a disabled woman. This discrimination brings with it a reluctance on the part of families, or rather decision makers within the families, to make tangible and intangible resources available to disabled women, thus further undermining their life chances… their social isolation as women is deepened by their disabled status’ (cited by Elwan, 1999: 29–30). She also cites a UNDP study that showed that women with disabilities were twice as prone as able-bodied women to suffer divorce, separation and violence. In some areas, mothers are blamed and stigmatised for giving birth to a child with a disability, while in others women with disabilities are kept hidden and thus socially isolated (see also Boylan, 1991: 3, 55–7).

While women have to bear the greater burden of caring for others, their own access to care and treatment appears to be limited in both the industrial and the developing countries. For example, the Economic and Social Commission for Asia and the Pacific (ESCAP) reports that commuting to rehabilitation centres poses serious difficulties for women and girls with disabilities, and is expensive for their families. The report maintains that access problems are more severe in rural areas, where high rates of illiteracy and longer distances compound the difficulties experienced by women with disabilities. Higher rates of blindness among rural women in India has also been attributed to the limited access that women and girls have to transport to areas where they can receive the necessary medical care for eye diseases. As Harriss-White (2003) observes, the process of care for people with disabilities in India is ‘socially constructed and extremely male-biased’. In a study of disability in three villages in India, for example, it was found that the percentages of adult males receiving treatment ranged between 53 per cent and 56 per cent, while for adult females the corresponding percentages ranged between 11 per cent and 39 per cent (see also Boylan, 1991: 28–9).

In general, both the risk of disability and its impact on poverty appear to be higher in rural than in urban areas. This is particularly true in South Africa, where under apartheid the former homeland areas were severely underfunded and deprived of social and economic services. For example, access to assistive devices, which play an important role in disabled people's perception of their disabilities and have been shown even to influence access to grants, is biased towards urban and white populations. As pointed out in South Africa's Integrated National Disability Strategy, the location of people in disadvantaged areas such as the former homelands has ‘had a particularly severe impact on people with disabilities who found themselves in an inhospitable environment, facing poor living conditions and unable to access the help they needed’:

The Disabled Children Action Group (DICAG) estimates that 98 per cent of mothers of children with disabilities living in rural areas are unemployed, semi-literate or functionally illiterate single women. Deserted by husbands and lovers, often socially ostracised by their communities, and banished into isolation by their extended families, they tend to withdraw into a world of their own. (RSA, 1997)

In a study of 200 graduates of special education institutions in Lebanon, Thomas and Lakkis (2003) found that while women graduates had higher educational levels than men, only 35 per cent of the women graduates were employed, as opposed to 52 per cent of the men graduates. In South Africa the Community Agency for Social Enquiry (CASE) survey found a statistically significant difference in the employment rates of men (15 per cent) and women (11 per cent) with disabilities (1998: 28).

5. IMPLICATIONS AND CONCLUSIONS

As Pokempner and Roberts (2001) have argued in relation to poverty and disability, ‘economic and social supports should seek to address both types of disadvantage rather than investing more resources in separating and grading the causes of each’:

The relationship between poverty and disability suggests that reducing the incidence of both requires more than the provision of meager economic support and the improvement or expansion of health care services. While these are very important aspects of an antipoverty program, our analysis calls for a broader vision of the factors promoting of health and illness, a more structural analysis of the causes of poverty, and attention to the relationship between the two.

The same logic applies to women and disability. The evidence that we have reviewed on gender and disability suggests that these are overlapping inequalities that reinforce one another to create greater vulnerability to deprivation and exploitation. A place must therefore be found for disability within women and gender studies, just as gender issues require more attention within disability studies. More specifically, women and gender studies need to pay more attention to what has been called the feminisation of poverty, and how various forms of inequality and disadvantage interact with one another to create extremes of deprivation and exclusion.

However, simply focusing on women and disability ignores other sources of deprivation and vulnerability such as poverty and race. It also fails to take into account how the burden of childcare and child support falls unequally on women, particularly within current demographic trends of female-headed households and early or teenage pregnancy. That these demographic trends are often associated with poverty and minority or disempowered racial or ethnic groups adds further saliency to the need to broaden our focus.

In recent years most of the major international development agencies have placed disability on their development agendas (see, for example, United Nations, 1997; USAID, 1997; DFID, 2000; NORAD, 2002; Wolfensohn, 2002, 2004; European Commission, 2003). These developments have begun to point the way towards a more integrated approach to disability, and have prompted the United Kingdom's Department for International Development, for example, to declare that ‘eliminating world poverty is unlikely to be achieved unless the rights and needs of people with disabilities are taken into account’ (DFID, 2000: 1). In recent years, World Bank President James Wolfensohn has repeatedly said that it would be impossible to conceive of achieving the Millennium Development Goals of halving poverty by 2015 without the inclusion of disability in development (2002, 2004).

At a recent conference on disability and development in Washington, DC, Wolfensohn suggested there might be a parallel between the issue of gender in development and that of disability:

Curiously, for quite a number of years, the issue of women, the issue of gender was an issue that was by early predecessors of mine given a backward place until we discovered that the key to development was, in fact, gender and that the secret weapon for development was, in fact, women. (Wolfensohn, 2004)

While there may be some similarities between the relationships of disability and gender to development, not least of which is the way they have been neglected in the past, there are also some major differences between the two as issues of development (it should be borne in mind that the acceptance of women as an important component of the development discourse was only achieved after decades of mobilisation and lobbying by the women's movement). One important difference is that while women make up about half of the world's population, people with disability account for a smaller, although by no means insignificant, part of the population [the World Bank (2004), for examples, estimates that there are 600 million people with disability in the world, with about 400 million living in developing countries]. This is likely to result in development agencies assigning a lower significance or priority to the issue of disability.

There are, however, two factors that may help to compensate for the devaluation of disability as an issue of development. The first of these is mortality. There are strong indications that people with disabilities have higher rates of mortality, and data from recent World Bank surveys suggest that ‘in some parts of the world, as many as 80 per cent of disabled children die before the age of 5, even in areas where the overall child mortality rate has been brought down to under 20 per cent’ (World Bank, 2004). Lower prevalence rates for disability in developing countries may therefore be a product of higher mortality rates among people with disabilities. If this is the case, then it is likely that those segments of the population that are most vulnerable to disability would also be most vulnerable to premature mortality. This in turn would have the effect of lowering disability rates among those parts of the population that one would expect to be most vulnerable to disability. To obtain a more comprehensive understanding of disability within developing contexts, it may therefore be necessary to locate disability trends within the context of mortality trends. As Hulme and Shepherd point out, how to deal with people who die preventable deaths is a key conceptual challenge for the study of poverty: ‘These need to be incorporated in our analysis as they experience the most acute form of deprivation (i.e. deprivation of all capabilities) for all of the “lost” years of the life they would have had’ (2003: 409).

A second factor that might challenge the low priority assigned to disability as an issue of development relates to the central theme of this article, namely that disability needs to be seen within the context of other forms of disadvantage such as gender, and that different forms of disadvantage and vulnerability are often cumulative and overlapping. Over the past two decades the idea that poverty is multidimensional has become part of the conventional wisdom of development. However, multidimensionality has largely been applied to the forms that poverty takes rather than its causes. If, as we have argued, disability interacts with other forms of disadvantage and inequality to create extreme forms of vulnerability and deprivation, then disability should be seen as an integral part of development rather than as a separate need competing for scarce development resources.

These issues are linked to the concept of intersectionality that derives from gender studies and that uses the metaphor of traffic intersections to understand the complexity of multiple identities and the various disadvantages and discriminations that result from these identities. Alison Symington, for example, defines intersectionality as ‘an analytical tool for studying, understanding and responding to the ways in which gender intersects with other identities and how these intersections contribute to unique experiences of oppression and privilege’ (2004: 2).

From the intersectional perspective, the intersection of different disadvantages or deprivations based on the combination of identities is not seen as cumulative (i.e. increasing the burden of the agent at the interstices of the deprivations) but rather as ‘producing substantively distinct experiences’ (Symington, 2004: 2). In our view, whether the impacts of multiple deprivations are cumulative or produce qualitatively different experiences is an empirical question, and the evidence presented on disability and gender in this article suggests that they may be both cumulative and non-cumulative. For example, in terms of quantifiable variables such as income, employment rates and educational levels, the data suggest that disadvantages associated with disability and gender may well be cumulative, whereas for other, more complex, variables such as the ways in which the stigma of disability impacts on the social roles and status of women may produce more qualitatively distinct experiences that are difficult to measure or quantify. The matter may go even further than this in that the cumulative impacts of disability and gender on income, for example, do not rule out other, more qualitative impacts.

However, more important to the central issues of this article is that the intersectional perspective encourages us to move away from binary thinking to a more global human rights perspective. Rather than seeing one person's rights as being gained at the expense of another's, intersectionality embraces the possibility that one can work simultaneously for one's own rights and the rights of others. Within this perspective, development becomes less about competitive advantages than about understanding the links between various disadvantages. From an intersectional perspective, therefore, the inclusion of disability in development is not so much a question of the importance of disability as yet another issue on the development agenda, but rather of the ‘bigger picture’ in which disability interacts with other disadvantages, such as gender and race for example, to create new or more extreme forms of deprivation and oppression.

Additional information

Notes on contributors

Erna Alant

Respectively, Independent Researcher working with Centre for Augmentative and Alternative Communication (CAAC), University of Pretoria; and Professor and Director, CAAC, University of Pretoria. The authors are grateful for the useful comments and suggestions made by the two anonymous reviewers of their article.

Notes