More than 30 years ago, the Declaration of Alma-Ata reported that "an acceptable level of health for all the people of the world by the year 2000" was possible, and urgently expressed the need for collective action to protect and promote health worldwide. At the time, the United Nations boldly challenged the global community to eliminate the inequality in the health status of people across developed and developing nations (WHO and UNICEF 1978). In the decades that have passed since Alma-Ata, the goal of health as a basic human right to which all individuals are entitled has remained largely unfulfilled. In recognition of a widening gap in health disparities between so-called developed and developing nations, the United Nations Development Program (UNDP) led a global initiative known as the Millennium Development Goals (MDGs) project. MDGs were adopted in 2000 as a strategy aimed at reducing disparities in human development within the international community by the year 2015. There are eight MDGs and a series of 180 related indicators, all geared at reducing health, social and economic disparities in a "timely" fashion. Although some countries have made advances, the odds are rather poor that the MDGs will be reached within the next 6 years (Koblinsky et al. 2008; Molyneux 2008).

In his article, Dr. Eskay weighs in on this debate regarding human development and argues that persons living with a disability are often marginalized and stigmatized by the attitudes, beliefs and behaviours that collectively form the cultural context in which they live. It is staggering to consider the estimation that over 600 million people worldwide live with a disability, and about 80% of persons with disabilities (PWDs) live in developing nations where standards of living are poor and access to healthcare is scarce (WHO 2001; Allapat et al. 2007). It may also be worthy to note that while disability is inherently linked to a nation's prospect for human development, it was not included (directly or indirectly) as an MDG (Landry et al. 2007). The direct and indirect loss of human potential due to disability is an expense that all countries will continue to struggle with in this new century. This may be particularly true as, due to medical advances, illnesses and conditions previously linked to high mortality such as cardiovascular disease and HIV/AIDS have emerged as chronic disabling conditions.

Dr. Eskay provides impressive insight into the cultural lens through which societies, whether small-scale or large-scale, view disability and PWDs. Moreover, the scientifically interesting (but at times morally reprehensible) rationale that forms the basis of rather pessimistic and paternalistic perspectives provides an understanding of the barriers that face PWDs on a daily basis. The link created between the culturally interpretive context of disability and access to health and social services for PWDs is a powerful social policy message. Overall, Dr. Eskay interprets the outcomes of poor access and low provision of services as a function of negative socio-cultural perceptions, and he argues reasonably well that community-culture context drives the way PWDs are perceived. In a sense, Dr. Eskay is suggesting that the cultural perception of disability and subsequent policy within a community is a strong predictor of the degree to which health and social services will be offered to PWDs in that same community. In other words, cultural perception in a community drives policy formulation, which in turn frames service delivery. This logic has also been reported among mothers of children with disabilities; if the mother has a positive attitude toward the disability and the future, she is more likely to seek services than her counterparts with poor or negative perceptions (Danesco 1997; Diken 2006).

I was recently reminded of this precarious missing link regarding cultural perspectives on disability and inclusion. We were implementing a development project aimed at scaling up education and capacity in the area of disability management among health and social sector workers in a low-income South Asian country. We invited a panel of PWDs to speak directly with the cohort of approximately 25 able-bodied persons (or as some might say, persons who are "not yet disabled"). The panel consisted of a person who had deafness, a person who had blindness, a person who used a wheelchair due to paraplegia and a person who used prosthetic limbs due to double amputations following a landmine blast. All panellists had planned to arrive early and were prepared to begin the session well ahead of time. On the other hand, all the participants in the session were, for one reason or another, delayed, and the panel discussion began hours later than scheduled. Notwithstanding the conceptualization of time in countries other than my own, persons who can't talk, can't see or can't walk were able to manage the chaotic morning traffic and architectural barriers of a capital city in a South Asian country and beat 25 so-called able-bodied persons to the education session. I wondered, who among us should be considered "disabled" and from which viewpoint? Based on this isolated event, it was surely not the panellists whom I would have considered disabled on that day. Dr. Eskay creates a framework through which to interpret the meaning of events such as the one describe here and reminds us that perception is indeed reality.

By all accounts, the global number of PWDs is growing, and the ramifications of disability will reach well beyond the health and social sector. Left unchecked they will undoubtedly affect economic and social infrastructure at the local, regional, national and international levels.

About the Author

Michel D. Landry PT, PhD, Assistant Professor, Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada

Adjunct Assistant Professor, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

President, Canadian Physiotherapy Association, Toronto, Ontario, Canada

References

Allapat, C., J. McFarland, B. McGovern, A. Penfold, G. Siu, S. Raman and M.D. Landry. 2007. "The Role of Physical Therapists in Global Health Initiative: A SWOT analysis." Physiotherapy Canada 59(4): 275-85.

Danesco, E.R. 1997. "Parental Beliefs on Childhood Disability: Insights on Culture, Child Development and Intervention." International Journal of Disability, Development and Education 44(1): 41-52.

Diken, I.H. 2006. "Turkish Mothers' Interpretation of the Disability of Their Children with Mental Retardation." International Journal of Special Education 21(2): 8-17.

Koblinsky, M., I. Anwar, M.K. Mridha, M.E.. Chowdhury and R. Botlero. 2008. "Reducing Maternal Mortality and Improving Maternal Health: Bangladesh and MDG 5." Journal of Health, Population and Nutrition 26(3): 280-94.

Landry, M.D., T. Dyck and S. Raman. 2007. "Poverty, Disability and Human Development: A Global Challenge for Physiotherapy in the Twenty-First Century." Physiotherapy 93: 233-4.

Molyneux, D.H. 2008. "Combating the 'Other Diseases' of MDG 6: Changing the Paradigm to Achieve Equity and Poverty Reduction?" Transactions of the Royal Society of Tropical Medicine and Hygiene; 102(6): 509-19.

World Health Organization. 2001. International Classification of Functioning, Disability and Health. World Health Assembly, Geneva, Switzerland. May 14-22, 2001. Geneva: WHO.

World Health Organization and UNICEF. 1978. Primary Health Care: Report of the International Conference on Primary Health Care. Alma-Ata USSR. September 6-12, 1978. Geneva: WHO.