REHABILITATION: A GLOBAL PERSPECTIVE

Lex Frieden
Rehabilitation International/TIRR/Baylor College of Medicine

Developments in the fields of technology and medicine during the past three decades have expanded opportunities for professionals in the field of medical rehabilitation, including physicians, nurses, therapists, and others.  These developments have also given hope to patients and former patients, and to their families.  Advances in surgery, pharmacology, and other fields of medicine and in the fields of engineering and science, have saved millions of lives.  In doing so, they have also provided challenges for patients and rehabilitationists.  Rehabilitation professionals and rehabilitation consumers (patients and their families) must find ways of adapting to the results and products of the new technologies which may extend lives, but which may not fully restore function.

In general, people are living longer and coincidently, they are far more likely to experience impairments and other chronic conditions.  With rehabilitation, most people with long-term impairments and chronic conditions, people with disabilities, can be stabilized from a medical standpoint.  Then, with coaching and practice, with the use of adaptive equipment, with certain environmental adaptations, and with assistance from others, they can reacquire needed functional capacities, to varying degrees.  The challenges of adapting classical rehabilitation methods and developing new ones in conjunction with the advent of new acute treatment interventions should continue to stimulate and invigorate the field of rehabilitation.

Just as rehabilitation most often follows acute intervention of some sort, community living most often follows rehabilitation.  The fact that more people with disabilities will be living in the community will provide another challenge for those in the field of physical medicine and rehabilitation.  But physiatrists and other rehabilitation team members will not face that challenge alone.  The challenge of accommodating large numbers of people with disabilities in the community will confront the whole society.

The question for society is: how will people with disabilities live in the community.  Historically, solutions have ranged from institutionalization to community-based independent living.  In recent years, people with disabilities have rejected institutionalization, and many rehabilitation professionals and policymakers have joined them in doing so.  If noninstitutional community living is to be the preferred option for people with disabilities in the future, then the recent paradigm shift away from nursing homes and other institution-like solutions must be accelerated.  The reality is that the population of people with disabilities in need of community living options is expanding and will continue to expand at a rate far greater than most of our communities can accommodate.

New approaches to ensuring independent living opportunities for people with disabilities must be explored and quickly implemented.  This will require cooperation between rehabilitation professionals, consumers, policymakers, and community leaders.  Accommodating growing numbers of people with disabilities in the community will require resources which have yet to be allocated for this purpose.  Resources will be needed to alter built environments, to adapt community services infrastructures, and to provide in-home attendant services.

Existing community services which will particularly be affected include housing, transportation, home health-care and telecommunications.  Attendant care or personal assistance services must be better developed, and communitywide service systems will need to be instituted in cities.  Other solutions must be devised to serve people in rural areas.  While action to identify and remove barriers to full participation by people with disabilities in the community has begun at some levels and in some jurisdictions, growing numbers of people with disabilities will accelerate demands for physical access, program accommodations, and appropriate service delivery.

Perhaps the greatest barrier to full participation by people with disabilities in the community is attitudinal.  Most often, such attitudinal barriers are manifested through discrimination, intentional and otherwise.  To remedy this, national and international standards for the accommodation and treatment of people with disabilities are now in the process of being updated and expanded.  New standards for nondiscrimination on the basis of disability are being installed in some countries, and the United Nations is considering a call for a treaty banning discrimination on the basis of disability and confirming equal rights for people with disabilities worldwide.