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Wednesday, October 30, 2019

Disability

From Wikipedia, the free encyclopedia
 
white line figure of a person seated over the axis of a wheel, blue background
According to many definitions, a disability or functional impairment is an impairment that may be cognitive, developmental, intellectual, mental, physical, sensory, or some combination of these. Other definitions describe disability as the societal disadvantage arising from such impairments. Disability substantially affects a person's life activities and may be present from birth or occur during a person's lifetime.
Disabilities is an umbrella term, covering impairments, activity limitations, and participation restrictions. An impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations. Disability is thus not just a health problem. It is a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society in which he or she lives.
— World Health Organization, Disabilities
Disability is a contested concept, with different meanings in different communities. The term disability may be used to refer to physical or mental attributes that some institutions, particularly medicine, view as needing to be fixed (the medical model); it may also refer to limitations imposed on people by the constraints of an ableist society (the social model); or the term may serve to refer to the identity of disabled people. Physiological functional capacity (PFC) is a measure of an individual's performance level that gauges one's ability to perform the physical tasks of daily life and the ease with which these tasks are performed. PFC declines with advancing age to result in frailty, cognitive disorders, or physical disorders, all of which may lead to labeling individuals as disabled.

Terminology

Handicapped
Handicap has been disparaged as a result of false folk etymology that claims it is a reference to begging. The term is actually derived from an old game, Hand-i'-cap, in which two players trade possessions and a third, neutral person judges the difference of value between the possessions. The concept of a neutral person evening up the odds was extended to handicap racing in the mid-18th century. In handicap racing, horses carry different weights based on the umpire's estimation of what would make them run equally. The use of the term to describe a person with a disability – by extension from handicap racing, a person carrying a heavier burden than normal – appeared in the early 20th century.
Access
The ability to go places and do things. People with certain types of disabilities struggle to get equal access to some things in society. For example, a blind person cannot read printed paper voting ballots, and therefore does not have access to voting that requires paper ballots.
Accommodation
A change that improves access. For example, if voting ballots are available in Braille or on a text-to-speech machine, or if another person read the ballot to the blind person and recorded the choices, then the blind person would have access to voting.

Types

There are many different types of disability. Often, disability is understood as a situation that produces a long-term impairment that affects activities of daily living, such as eating, walking, and maintaining personal hygiene.
Acquired disability
A disability that the person was not born with. For example, Alzheimer's disease produces an acquired disability in previously healthy people.
Invisible disability
An invisible disability is a disability that is not immediately noticeable.
Temporary disability
A disability that is expected to resolve over time, such as treatment for cancer.
For the purposes of the Americans with Disabilities Act of 1990, the US Equal Employment Opportunity Commission regulations provide a list of conditions that should easily be concluded to be disabilities: deafness, blindness, an intellectual disability (formerly termed mental retardation), partially or completely missing limbs or mobility impairments requiring the use of a wheelchair, autism, cancer, cerebral palsy, diabetes, epilepsy, HIV/AIDS, multiple sclerosis, muscular dystrophy, major depressive disorder, bipolar disorder, post-traumatic stress disorder, obsessive compulsive disorder, and schizophrenia.

History

Contemporary understandings of disability derive from concepts that arose during the West's scientific Enlightenment; prior to the Enlightenment, physical differences were viewed through a different lens. 

During the Middle Ages, madness and other conditions were thought to be caused by demons. They were also thought to be part of the natural order, especially during and in the fallout of the Plague, which wrought impairments throughout the general population. In the early modern period there was a shift to seeking biological causes for physical and mental differences, as well as heightened interest in demarcating categories: for example, Ambroise Pare, in the sixteenth century, wrote of "monsters", "prodigies", and "the maimed". The European Enlightenment's emphases on knowledge derived from reason and on the value of natural science to human progress helped spawn the birth of institutions and associated knowledge systems that observed and categorized human beings; among these, the ones significant to the development of today's concepts of disability were asylums, clinics, and, prisons.

Contemporary concepts of disability are rooted in eighteenth- and nineteenth-century developments. Foremost among these was the development of clinical medical discourse, which made the human body visible as a thing to be manipulated, studied, and transformed. These worked in tandem with scientific discourses that sought to classify and categorize and, in so doing, became methods of normalization.

The concept of the "norm" developed in this time period, and is signaled in the work of the Belgian statistician, sociologist, mathematician, and astronomer Adolphe Quetelet, who wrote in the 1830s of l'homme moyen – the average man. Quetelet postulated that one could take the sum of all people's attributes in a given population (such as their height or weight) and find their average, and that this figure should serve as a norm toward which all should aspire.

This idea of a statistical norm threads through the rapid take up of statistics gathering by Britain, United States, and the Western European states during this time period, and it is tied to the rise of eugenics. Disability, as well as other concepts including: abnormal, non-normal, and normalcy came from this. The circulation of these concepts is evident in the popularity of the freak show, where showmen profited from exhibiting people who deviated from those norms.

With the rise of eugenics in the latter part of the nineteenth century, such deviations were viewed as dangerous to the health of entire populations. With disability viewed as part of a person's biological make-up and thus their genetic inheritance, scientists turned their attention to notions of weeding such "deviations" out of the gene pool. Various metrics for assessing a person's genetic fitness, which were then used to deport, sterilize, or institutionalize those deemed unfit. At the end of the Second World War, with the example of Nazi eugenics, eugenics faded from public discourse, and increasingly disability cohered into a set of attributes that medicine could attend to – whether through augmentation, rehabilitation, or treatment. In both contemporary and modern history, disability was often viewed as a by-product of incest between first-degree relatives or second-degree relatives.

In the early 1970s, disability activists began to challenge how society treated disabled people and the medical approach to disability. Due to this work, physical barriers to access were identified. These conditions functionally disabled them, and what is now known as the social model of disability emerged. Coined by Mike Oliver in 1983, this phrase distinguishes between the medical model of disability – under which an impairment needs to be fixed – and the social model of disability – under which the society that limits a person needs to be fixed.

Sociology

crutches, braces, photographs, and other exhibits
Museum of disABILITY History, Buffalo, New York.

People-first language

People-first language is one way to talk about disability that some people prefer. Many others prefer identity-first language. Using people-first language is said to put the person before the disability, so those individuals who prefer people-first language, prefer to be called, "a person with a disability". This style is reflected in major legislation on disability rights, including the Americans with Disabilities Act and the UN Convention on the Rights of Persons with Disabilities.

For people-first guidelines, check out, "Cerebral Palsy: A Guide for Care" at the University of Delaware:
"The American Psychological Association style guide states that, when identifying a person with a disability, the person's name or pronoun should come first, and descriptions of the disability should be used so that the disability is identified, but is not modifying the person. Acceptable examples included "a woman with Down syndrome" or "a man who has schizophrenia". It also states that a person's adaptive equipment should be described functionally as something that assists a person, not as something that limits a person, for example, "a woman who uses a wheelchair" rather than "a woman in/confined to a wheelchair".
A similar kind of "people-first" terminology is also used in the UK, but more often in the form "people with impairments" (such as "people with visual impairments"). However, in the UK, identity-first language is generally preferred over people-first language. 

The use of “people-first” terminology has given rise to the use of the acronym PWD to refer to person(s) (or people) with disabilities (or disability). However other individuals and groups prefer identity-first language to emphasize how a disability can impact people's identities. Which style of language used varies between different countries, groups and individuals.

Identity-first language

In contrast to people-first language, identity-first language describes the person as "disabled". Some people prefer this and argue that this fits the social model even better than does people-first language, as it emphasizes that the person is disabled not by their body, but by a world that does not accommodate them.

This is especially true in the UK, where it is argued under the social model that while someone's impairment (for example, having a spinal cord injury) is an individual property, "disability" is something created by external societal factors such as a lack of accessibility. This distinction between the individual property of impairment and the social property of disability is central to the social model. The term "disabled people" as a political construction is also widely used by international organisations of disabled people, such as Disabled Peoples' International (DPI).

Using identity-first language also parallels how people talk about other aspects of identity and diversity. For example:
“In the autism community, many self-advocates and their allies prefer terminology such as ‘Autistic,’ ‘Autistic person,’ or ‘Autistic individual’ because we understand autism as an inherent part of an individual’s identity — the same way one refers to ‘Muslims,’ ‘African-Americans,’ ‘Lesbian/Gay/Bisexual/Transgender/Queer,’ ‘Chinese,’ ‘gifted,’ ‘athletic,’ or ‘Jewish.’”
Similarly, the Deaf community rejects people-first language in favor of identity-first language.

Aging

To a certain degree, physical impairments and changing mental states are almost ubiquitously experienced by people as they age. Aging populations are often stigmatized for having a high prevalence of disability. Kathleen Woodward, writing in Key Words for Disability Studies, explains the phenomenon as follows:
Aging is invoked rhetorically – at times ominously – as a pressing reason why disability should be of crucial interest to all of us (we are all getting older, we will all be disabled eventually), thereby inadvertently reinforcing the damaging and dominant stereotype of aging as solely an experience of decline and deterioration. But little attention has been given to the imbrication of aging and disability.

Employment

Studies have illustrated a correlation between disability and poverty. Notably, jobs offered to disabled people are scarce. In the developed world there are programs in place that aid intellectually disabled (ID) people to acquire skills they need in the workforce. Such programs include sheltered workshops and adult day care programs. Sheltered programs consist of daytime activities such as, gardening, manufacturing, and assembling. These activities facilitate routine-oriented tasks that in turn allow intellectually disabled people to gain experience before entering the workforce. Similarly, adult day care programs also include day time activities. However, these activities are based in an educational environment where intellectually disabled are able to engage in educational, physical, and communication based tasks. This educational based environment helps facilitate communication, memory, and general living skills. In addition, adult day care programs arrange opportunities for their students to engage in community activities. Such opportunities are arranged by scheduling field trips to public places (e.g. Disneyland, Zoo, and Movie Theater). Despite, both programs providing essential skills for intellectually disabled prior to entering the workforce researchers have found that intellectually disabled people prefer to be involved with community-integrated employment. Community-integrated employment are job opportunities offered to intellectually disabled people at minimum wage or a higher rate depending on the position. Community-integrated employment comes in a variety of occupations ranging from customer service, clerical, janitorial, hospitality and manufacturing positions. Within their daily tasks community-integrated employees work alongside employees who do not have disabilities, but who are able to assist them with training. All three options allow intellectually disabled people to develop and exercise social skills that are vital to everyday life. However, it is not guaranteed that community-integrated employees receive the same treatment as employees that do not have ID. According to Lindstrom, Hirano, McCarthy, and Alverson, community-integrated employees are less likely to receive raises. In addition, studies conducted in 2013 illustrated only 26% of employees with ID retained full-time status.

Furthermore, many with disabilities, intellectual and (or) psychical, finding a stable workforce poses many challenges. According to a study conducted by JARID (Journal of Applied Research and Intellectual Disability, indicates that although finding a job may be difficult for an intellectually disabled individual, stabilizing a job is even harder. This is largely due to two main factors: production skills and effective social skills. This idea is supported by Chadsey-Rusch, who claims that securing employment for the intellectually disabled, requires adequate production skills and effective social skills. However, other underlying factors for job loss include, structural factors and the integration between worker and workplace. As stated by Kilsby, limited structural factors can effect a multitude of factors in a job. Factors such as a restricted number of hours an intellectually disabled person is allowed to work. This in return, according to Fabian, Wistow, and Schneider leads to a lack of opportunity to develop relationships with coworkers and a chance to better integrate within the workplace. Nevertheless, those who are unable to stabilize a job often are left discouraged. According to the same study conducted by JARED, many who had participated, found that they had made smaller incomes when compared to their co-workers, had an excess of time throughout their days, because they did not have work. They also had feelings of hopelessness and failure. According to the NOD ( National Organization On Disability), not only do the (ID) face constant discouragement, but many live below the poverty line, because they are unable to find or stabilize employment and (or) because of employee restricting factors placed on ID workers. This then causes the (ID) the incapacity to provide for themselves basic necessities one needs. Items such as, food, medical care, transportation, and housing.

Poverty

painting of a group of people, some missing feet, hunched over crutches as a beggar walks past
There is a global correlation between disability and poverty, produced by a variety of factors. Disability and poverty may form a vicious circle, in which physical barriers and stigma of disability make it more difficult to get income, which in turn diminishes access to health care and other necessities for a healthy life. The World report on disability indicates that half of all disabled people cannot afford health care, compared to a third of abled people. In countries without public services for adults with disabilities, their families may be impoverished.

Disasters

There is limited research knowledge, but many anecdotal reports, on what happens when disasters impact disabled people. Individuals with disabilities are greatly affected by disasters. Those with physical disabilities can be at risk when evacuating if assistance is not available. Individuals with cognitive impairments may struggle with understanding instructions that must be followed in the event a disaster occurs. All of these factors can increase the degree of variation of risk in disaster situations with disabled individuals.

Research studies have consistently found discrimination against individuals with disabilities during all phases of a disaster cycle. The most common limitation is that people cannot physically access buildings or transportation, as well as access disaster-related services. The exclusion of these individuals is caused in part by the lack of disability-related training provided to emergency planners and disaster relief personnel.

Theory

The International Classification of Functioning, Disability and Health (ICF), produced by the World Health Organization, distinguishes between body functions (physiological or psychological, such as vision) and body structures (anatomical parts, such as the eye and related structures). Impairment in bodily structure or function is defined as involving an anomaly, defect, loss or other significant deviation from certain generally accepted population standards, which may fluctuate over time. Activity is defined as the execution of a task or action. The ICF lists 9 broad domains of functioning which can be affected:
  • Learning and applying knowledge
  • General tasks and demands
  • Communication
  • Basic physical mobility, Domestic life, and Self-care (for example, activities of daily living)
  • Interpersonal interactions and relationships
  • Community, social and civic life, including employment
  • Other major life areas
In concert with disability scholars, the introduction to the ICF states that a variety of conceptual models have been proposed to understand and explain disability and functioning, which it seeks to integrate. These models include the following:

Medical model

The medical model views disability as a problem of the person, directly caused by disease, trauma, or other health conditions which therefore requires sustained medical care in the form of individual treatment by professionals. In the medical model, management of the disability is aimed at a "cure", or the individual's adjustment and behavioral change that would lead to an "almost-cure" or effective cure. In the medical model, medical care is viewed as the main issue, and at the political level, the principal response is that of modifying or reforming healthcare policy.

Social model

The social model of disability sees "disability" as a socially created problem and a matter of the full integration of individuals into society. In this model, disability is not an attribute of an individual, but rather a complex collection of conditions, created by the social environment. The management of the problem requires social action and it is the collective responsibility of society to create a society in which limitations for disabled people are minimal. Disability is both cultural and ideological in creation. According to the social model, equal access for someone with an impairment/disability is a human rights concern. The social model of disability has come under criticism. While recognizing the importance played by the social model in stressing the responsibility of society, scholars, including Tom Shakespeare, point out the limits of the model, and urge the need for a new model that will overcome the "medical vs. social" dichotomy. The limitations of this model mean that often the vital services and information persons with disabilities face are simply not available, often due to limited economic returns in supporting them.

Some say medical humanities is a fruitful field where the gap between the medical and the social model of disability might be bridged.

Social construction

The social construction of disability is the idea that disability is constructed by social expectations and institutions rather than biological differences. Highlighting the ways society and institutions construct disability is one of the main focuses of this idea. In the same way that race and gender are not biologically fixed, neither is disability. 

Around the early 1970s, sociologists, notably Eliot Friedson, began to argue that labeling theory and social deviance could be applied to disability studies. This led to the creation of the social construction of disability theory. The social construction of disability is the idea that disability is constructed as the social response to a deviance from the norm. The medical industry is the creator of the ill and disabled social role. Medical professionals and institutions, who wield expertise over health, have the ability to define health and physical and mental norms. When an individual has a feature that creates an impairment, restriction, or limitation from reaching the social definition of health, the individual is labeled as disabled. Under this idea, disability is not defined by the physical features of the body but by a deviance from the social convention of health.

Social construction of disability would argue that the medical model of disability's view that a disability is an impairment, restriction, or limitation is wrong. Instead what is seen as a disability is just a difference in the individual from what is considered "normal" in society.

Other models

  • The spectrum model refers to the range of audibility, sensibility, and visibility under which people function. The model asserts that disability does not necessarily mean reduced spectrum of operations. Rather, disability is often defined according to thresholds set on a continuum of disability.
  • The moral model refers to the attitude that people are morally responsible for their own disability. For example, disability may be seen as a result of bad actions of parents if congenital, or as a result of practicing witchcraft if not. Echoes of this can be seen in the doctrine of karma in Indian religions. It also includes notions that a disability gives a person "special abilities to perceive, reflect, transcend, be spiritual".
  • The expert/professional model has provided a traditional response to disability issues and can be seen as an offshoot of the medical model. Within its framework, professionals follow a process of identifying the impairment and its limitations (using the medical model), and taking the necessary action to improve the position of the disabled person. This has tended to produce a system in which an authoritarian, over-active service provider prescribes and acts for a passive client.
  • The tragedy/charity model depicts disabled people as victims of circumstance who are deserving of pity. This, along with the medical model, are the models most used by non-disabled people to define and explain disability.
  • The legitimacy model views disability as a value-based determination about which explanations for the atypical are legitimate for membership in the disability category. This viewpoint allows for multiple explanations and models to be considered as purposive and viable.
  • The social adapted model states although a person's disability poses some limitations in an able-bodied society, often the surrounding society and environment are more limiting than the disability itself.
  • The economic model defines disability in terms of reduced ability to work, the related loss of productivity and economic effects on the individual, employer and society in general.
  • The empowering model (also, customer model) allows for the person with a disability and his/her family to decide the course of his/her treatment. This turns the professional into a service provider whose role is to offer guidance and carry out the client's decisions. This model "empowers" the individual to pursue his/her own goals.
  • The market model of disability is minority rights and consumerist model of disability that recognizing disabled people and their stakeholders as representing a large group of consumers, employees and voters. This model looks to personal identity to define disability and empowers people to chart their own destiny in everyday life, with a particular focus on economic empowerment. By this model, based on US Census data, there are 1.2 billion people in the world who consider themselves to have a disability. "This model states that, due to the size of the demographic, companies and governments will serve the desires, pushed by demand as the message becomes prevalent in the cultural mainstream."
  • The consumer model of disability is based upon the “rights-based" model and claims that disabled people should have equal rights and access to products, goods and services offered by businesses. The consumer model extends the rights-based model by proposing that businesses, not only accommodate customers with disabilities under the requirements of legislation, but that businesses actively seek, market to, welcome and fully engage disabled people in all aspects of business service activities. The model suggests that all business operations, for example websites, policies and procedures, mission statements, emergency plans, programs and services, should integrate access and inclusion practices. Furthermore, these access and inclusion practices should be based on established customer service access and inclusion standards that embrace and support the active engagement of people of all abilities in business offerings. In this regard, specialized products and specialized services become important, such as auxiliary means, protheses, special foods, domestic help, and assisted living.
  • Different theories revolve around prejudice, stereotyping, discrimination, and stigma related to disability. One of the more popular ones, as put by Weiner, Perry, and Magnusson 's (1988) work with attribution theory, physical stigmas are perceived as to be un-controllable and elicit pity and desire to help, whereas, mental-behavioral stigmas are considered to be controllable and therefore elicit anger and desire to neglect the individuals with disabilities.
  • The ‘just world hypothesis’ talks about how a person is viewed as deserving the disability. And because it is the fault of that person, an observer does not feel obligated to feel bad for him or to help him.

Identity

In contexts where their differences are visible, persons with disabilities often face stigma. People frequently react to disabled presence with fear, pity, patronization, intrusive gazes, revulsion, or disregard. These reactions can, and often do, exclude persons with disabilities from accessing social spaces along with the benefits and resources these spaces provide. Disabled writer/researcher Jenny Morris describes how stigma functions to marginalize persons with disabilities:
“Going out in public so often takes courage. How many of us find that we can't dredge up the strength to do it day after day, week after week, year after year, a lifetime of rejection and revulsion? It is not only physical limitations that restrict us to our homes and those whom we know. It is the knowledge that each entry into the public world will be dominated by stares, by condescension, by pity and by hostility.”
Additionally, facing stigma can cause harm to psycho-emotional well-being of the person being stigmatized. One of the ways in which the psycho-emotional health of persons with disabilities is adversely affected is through the internalization of the oppression they experience, which can lead to feeling that they are weak, crazy, worthless, or any number of other negative attributes that may be associated with their conditions. Internalization of oppression damages the self-esteem of the person affected and shapes their behaviors in ways that are compliant with nondisabled dominance. Ableist ideas are frequently internalized when disabled people are pressured by the people and institutions around them to hide and downplay their disabled difference, or, "pass". According to writer Simi Linton, the act of passing takes a deep emotional toll by causing disabled individuals to experience loss of community, anxiety and self-doubt. The media play a significant role in creating and reinforcing stigma associated with disability. Media portrayals of disability usually cast disabled presence as necessarily marginal within society at large. These portrayals simultaneously reflect and influence the popular perception of disabled difference.

Tropes

There are distinct tactics that the media frequently employ in representing disabled presence. These common ways of framing disability are heavily criticized for being dehumanizing and failing to place importance on the perspectives of persons with disabilities.

Inspiration porn

Inspiration porn refers to portrayals of persons with disabilities in which they are presented as being inspiring simply because the person has a disability. These portrayals are criticized because they are created with the intent of making non-disabled viewers feel better about themselves in comparison to the individual portrayed. Rather than recognizing the humanity of persons with disabilities, inspiration porn turns them into objects of inspiration for a non-disabled audience.

Supercrip

The supercrip trope refers to instances when media reports on or portray a disabled person who has made a noteworthy achievement; but center on their disability rather than what they actually did. They are portrayed as awe-inspiring for being exceptional compared to others with the same or similar conditions. This trope is widely used in reporting on disabled athletes as well as in portrayals of autistic savants.

Many disabled people denounce these representations as reducing people to their condition rather than viewing them as full people. Furthermore, supercrip portrayals are criticized for creating the unrealistic expectation that disability should be accompanied by some type of special talent, genius, or insight.

Disabled villain

Characters in fiction that bear physical or mental markers of difference from perceived societal norms are frequently positioned as villains within a text. Lindsey Row-Heyveld notes, for instance, “that villainous pirates are scraggly, wizened, and inevitably kitted out with a peg leg, eye patch, or hook hand whereas heroic pirates look like Johnny Depp's Jack Sparrow.” Disabled people's visible differences from the abled majority are meant to evoke fear in audiences that can perpetuate the mindset of disabled people being a threat to individual or public interests and well-being.

Self advocacy

Some disabled people have attempted to resist marginalisation through the use of the social model in opposition to the medical model; with the aim of shifting criticism away from their bodies and impairments and towards the social institutions that oppress them relative to their abled peers. Disability activism that demands many grievances be addressed, such as lack of accessibility, poor representation in media, general disrespect, and lack of recognition, originates from a social model framework. 

Embracing disability as a positive identity by becoming involved in disabled communities and participating in disabled culture can be an effective way to combat internalised prejudice; and can challenge dominant narratives about disability.

Intersections

The experiences that disabled people have navigating social institutions vary greatly as a function of what other social categories they may belong to. The categories that intersect with disability to create unique experiences of ableism include, but aren't limited to, race and gender. The United Nations Convention on the Rights of Persons with Disabilities differentiates two kinds of disability intersection, race disability intersection and gender disability intersection.

Race

Disabled people who are also racial minorities generally have less access to support and are more vulnerable to violent discrimination. For example, in the United States people of color who are mentally ill are more frequently victims of police brutality than their white counterparts. Camille A. Nelson, writing for the Berkeley Journal of Criminal Law, notes that for “people who are negatively racialized, that is people who are perceived as being non-white, and for whom mental illness is either known or assumed, interaction with police is precarious and potentially dangerous.”

Gender

The marginalization of disabled people can leave persons with disabilities unable to actualize what society expects of gendered existence. This lack of recognition for their gender identity can leave persons with disabilities with feelings of inadequacy. Thomas J. Gerschick of Illinois State University describes why this denial of gendered identity occurs:
Bodies operate socially as canvases on which gender is displayed and kinesthetically as the mechanisms by which it is physically enacted. Thus, the bodies of disabled people make them vulnerable to being denied recognition as women and men.
To the extent that women and men with disabilities are gendered, the interactions of these two identities lead to different experiences. Disabled women face a sort of “double stigmatization” in which their membership to both of these marginalized categories simultaneously exacerbates the negative stereotypes associated with each as they are ascribed to them. According to The UN Woman Watch, "Persistence of certain cultural, legal and institutional barriers makes women and girls with disabilities the victims of two-fold discrimination: as women and as persons with disabilities." As Rosemarie Garland-Thomson puts it, “Women with disabilities, even more intensely than women in general, have been cast in the collective cultural imagination as inferior, lacking, excessive, incapable, unfit, and useless.”

Assistive technology

Assistive Technology is a generic term for devices and modifications (for a person or within a society) that help overcome or remove a disability. The first recorded example of the use of a prosthesis dates to at least 1800 BC. The wheelchair dates from the 17th century. The curb cut is a related structural innovation. Other examples are standing frames, text telephones, accessible keyboards, large print, Braille, & speech recognition software. Disabled people often develop personal or community adaptations, such as strategies to suppress tics in public (for example in Tourette's syndrome), or sign language in deaf communities. 

As the personal computer has become more ubiquitous, various organizations have formed to develop software and hardware to make computers more accessible for disabled people. Some software and hardware, such as Voice Finger, Freedom Scientific's JAWS, the Free and Open Source alternative Orca etc. have been specifically designed for disabled people while other software and hardware, such as Nuance's Dragon NaturallySpeaking, were not developed specifically for disabled people, but can be used to increase accessibility. The LOMAK keyboard was designed in New Zealand specifically for persons with disabilities. The World Wide Web consortium recognised a need for International Standards for Web Accessibility for persons with disabilities and created the Web Accessibility Initiative (WAI). As at Dec 2012 the standard is WCAG 2.0 (WCAG = Web Content Accessibility Guidelines).

Adapted sports

an athlete tilts his wheelchair and raises an arm to block his opponent's shot
Wheelchair basketball match between South Africa and Iran at the 2008 Summer Paralympics
 
The Paralympic Games (meaning "alongside the Olympics") are held after the (Summer and Winter) Olympics. The Paralympic Games include athletes with a wide range of physical disabilities. In member countries, organizations exist to organize competition in the Paralympic sports on levels ranging from recreational to elite (for example, Disabled Sports USA and BlazeSports America in the United States). 

The Paralympics developed from a rehabilitation programme for British war veterans with spinal injuries. In 1948, Sir Ludwig Guttman, a neurologist working with World War II veterans with spinal injuries at Stoke Mandeville Hospital in Aylesbury in the UK, began using sport as part of the rehabilitation programmes of his patients. 

In 2006, the Extremity Games were formed for physically disabled people, specifically limb loss or limb difference, to be able to compete in extreme sports.

Rights and government policies

Rights movement

The disability rights movement aims to secure equal opportunities and equal rights for disabled people. The specific goals and demands of the movement are accessibility and safety in transportation, architecture, and the physical environment; equal opportunities in independent living, employment, education, and housing; and freedom from abuse, neglect, and violations of patients' rights. Effective civil rights legislation is sought to secure these opportunities and rights.

The early disability rights movement was dominated by the medical model of disability, where emphasis was placed on curing or treating disabled people so that they would adhere to the social norm, but starting in the 1960s, rights groups began shifting to the social model of disability, where disability is interpreted as an issue of discrimination, thereby paving the way for rights groups to achieve equality through legal means.

Policies and actions

Convention on the Rights of Persons with Disabilities

On December 13, 2006, the United Nations formally agreed on the Convention on the Rights of Persons with Disabilities, the first human rights treaty of the 21st century, to protect and enhance the rights and opportunities of the world's estimated 650 million disabled people. As of April 2011, 99 of the 147 signatories had ratified the Convention. Countries that sign the convention are required to adopt national laws, and remove old ones, so that persons with disabilities will, for example, have equal rights to education, employment, and cultural life; to the right to own and inherit property; to not be discriminated against in marriage, etc.; and to not be unwilling subjects in medical experiments. UN officials, including the High Commissioner for Human Rights, have characterized the bill as representing a paradigm shift in attitudes toward a more rights-based view of disability in line with the social model.

International Year of Disabled Persons

In 1976, the United Nations began planning for its International Year of Disabled Persons (1981), later renamed the International Year of Disabled Persons. The UN Decade of Disabled Persons (1983–1993) featured a World Programme of Action Concerning Disabled Persons. In 1979, Frank Bowe was the only person with a disability representing any country in the planning of IYDP-1981. Today, many countries have named representatives who are themselves individuals with disabilities. The decade was closed in an address before the General Assembly by Robert Davila. Both Bowe and Davila are deaf. In 1984, UNESCO accepted sign language for use in education of deaf children and youth.

Policies in the United States

In the United States, the Department of Labor's 2014 rules for federal contractors, defined as companies that make more than $50,000/year from the federal government, required them to have as a goal that 7% of their workforce must be disabled people. In schools, the ADA says that all classrooms must be wheelchair accessible. The U.S. Architectural and Transportation Barriers Compliance Board, commonly known as the Access Board, created the Rehabilitation Act of 1973 to help offer guidelines for transportation and accessibility for the physically disabled.

About 12.6% of the U.S. population are individuals who suffer from a mental or physical disability. Many are unemployed because of prejudiced assumptions that a person with disabilities is unable to complete tasks that are commonly required in the workforce. This became a major Human rights issue because of the discrimination that this group faced when trying to apply for jobs in the U.S. Many advocacy groups protested against such discrimination, asking the federal government to implement laws and policies that would help individuals with disabilities.
Rehabilitation Act of 1973
The Rehabilitation Act of 1973 was enacted with the purpose of protecting individuals with disabilities from prejudicial treatment by government funded programs, employers, and agencies. The Rehabilitation Act of 1973 has not only helped protect U.S. citizens from being discriminated against but it has also created confidence amongst individuals to feel more comfortable with their disability. There are many sections within The Rehabilitation Act of 1973, that contains detailed information about what is covered in this policy.
Section 501
An employer must hire an individual who meets the qualifications of a job description despite any preexisting disabilities.
Section 503
Requires contractors or subcontractors, who receive more than $10,000 from the government to hire people with disabilities and to accommodate them with the needs that they need to achieve in the work force.
Section 504
States that receive federal money may not discriminate against any person with disabilities who qualifies for a program or job.
On June 22, 1999 the United States Supreme Court issued a ruling in Olmstead vs. L. C. that said unjustified segregation of persons with disabilities constitutes discrimination in violation of title II of the Americans with Disabilities Act. This has been interpreted as meaning people with disabilities must be given all opportunity by government to stay in their own homes as opposed to assisted living, nursing homes or worse, institutions for the disabled. It's been interpreted as meaning government must make all reasonable efforts to allow people with disabilities to be included in their respective communities and enjoy family and friends, work if possible, get married, own homes and interact with nondisabled people. This is why the United States has so many community based services today for the disabled including but not limited to home health aides, personal care attendants and other programs to keep people with disabilities in their own homes and communities.
The Americans with Disabilities Act of 1990
The federal government enacted The Americans with Disabilities Act of 1990, which was created to allow equal opportunity for jobs, access to private and government funded facilities, and transportation for disabled people. This act was created with the purpose to ensure that employers would not discriminate against any individual despite their disability. In 1990, data was gathered to show the percentage of disabled people who worked in the U.S. Out of the 13% who filled out the survey, only 53% percent of individuals with disabilities worked while 90% of this group population did not, the government wanted to change this, they wanted Americans with disabilities to have the same opportunities as those who did not have a disability. The ADA not only required corporations to hire disabled people but that they also accommodate them and their needs.
Title I
Employment
An employer must give a qualified individual with disabilities the same opportunities as any other employee despite their disability. The employer must offer equal work privileges to someone who has a disability including but not limited to pay, work hours, training, etc. The employer must also create accommodations suitable for the person and their physical or mental disabilities.
Title II
State and Local Government Activities
Requires that the government give disabled people the same opportunities involving work, programs, building access, and services. Title II also requires that buildings create easy access for disabled people and provide communicators who will be able to help those with hearing or speaking impairments. Public spaces are however not required to create accommodations that would in turn alter their services as long as the services proved that they did all they could to prevent discrimination against disabled people.
Title II
Transportation
Public transportation should be customized so that disabled people may have easy access to public transit. Paratransit is a service that provides transportation to people who are unable to get from one destination to another due to their mental or physical disability.
Title II
Public Accommodations
Public accommodations require that private businesses create accommodations that will allow disabled people easy access to buildings. Private businesses may not discriminate against disabled people and must provide accommodations that are reasonable, alterations may be made so that a person with disabilities can have equal access to facilities that are provided, communicators for the hearing impaired, devices for the visually impaired, and wheelchair access. Facilities must regulate with the ADA, when regulating the buildings infrastructure so it meets the ADA regulations.
Title IV
Telecommunication Relay Services
Requires telephone companies to have TRS seven days a week, twenty four hours a day. It requires telephone companies to create accommodations for deaf/hard of hearing people by providing a third party that will be able to assistant both parties in communicating with one another.

Policies in the United Kingdom

In the UK, the Department for Work and Pension is a government department responsible for promoting disability awareness and among its aims is to increase the understanding of disability and removal of barriers for disabled people in the workplace. According to a news report, a people survey conducted in the UK shows a 23% increase in reported discrimination and harassment in the workplace at The Department for Work and Pension. The survey shows the number of reports for discrimination due to disability was in majority compared to discrimination due to gender, ethnicity or age. DWP received criticism for the survey results. As a department responsible for tackling discrimination at work, the DWP results may indicate room for improvement from within. A DWP spokesperson said the survey results do not necessarily indicate an increase in the number of reports, but rather reflecting the outcomes of efforts to encourage people to come forward.

Political issues

woman seated in a wheelchair with military personnel in background
A 28-year-old Iraqi woman who lost both of her legs during the Iraq War in 2005
 
Political rights, social inclusion and citizenship have come to the fore in developed and some developing countries. The debate has moved beyond a concern about the perceived cost of maintaining dependent disabled people to finding effective ways to ensure that disabled people can participate in and contribute to society in all spheres of life. 

In developing nations, where the vast bulk of the estimated 650 million disabled people reside, a great deal of work is needed to address concerns ranging from accessibility and education to self-empowerment, self-supporting employment, and beyond.

In the past few years, disability rights activists have focused on obtaining full citizenship for the disabled.

There are obstacles in some countries in getting full employment; public perception of disabled people may vary.

Abuse

Disability abuse happens when a person is abused physically, financially, verbally or mentally due to the person having a disability. As many disabilities are not visible (for example, asthma, learning disabilities) some abusers cannot rationalize the non-physical disability with a need for understanding, support, and so on.

As the prevalence of disability and the cost of supporting disability increases with medical advancement and longevity in general, this aspect of society becomes of greater political importance. How political parties treat their disabled constituents may become a measure of a political party's understanding of disability, particularly in the social model of disability.

Insurance

Disability benefit, or disability pension, is a major kind of disability insurance that is provided by government agencies to people who are temporarily or permanently unable to work due to a disability. In the U.S., disability benefit is provided in the category of Supplemental Security Income. In Canada, it is within the Canada Pension Plan. In other countries, disability benefit may be provided under social security systems. 

Costs of disability pensions are steadily growing in Western countries, mainly in Europe and the United States. It was reported that, in the UK, expenditure on disability pensions accounted for 0.9% of gross domestic product (GDP) in 1980; two decades later it had reached 2.6% of GDP.[91][93] Several studies have reported a link between increased absence from work due to sickness and elevated risk of future disability pension.

A study by researchers in Denmark suggests that information on self-reported days of absence due to sickness can be used to effectively identify future potential groups for disability pension. These studies may provide useful information for policy makers, case managing authorities, employers, and physicians.

In Switzerland, social policies in the field of disability have been significantly reshaped over the last two decades by reducing the number of allowances awarded and by increasing the recourse to vocational rehabilitation measures. Drawing on interviews conducted with individuals who have been involved in programmes set up by Swiss disability insurance, a study highlights their uncertainties and concerns relating to their place in society, as well as their reactions to disability insurance's interventions.

Private, for-profit disability insurance plays a role in providing incomes to disabled people, but the nationalized programs are the safety net that catch most claimants.

Demographics

Estimates of worldwide and country-wide numbers of individuals with disabilities are problematic. The varying approaches taken to defining disability notwithstanding, demographers agree that the world population of individuals with disabilities is very large. For example, in 2012, the World Health Organization estimated a world population of 6.5 billion people. Of those, nearly 650 million people, or 10%, were estimated to be moderately or severely disabled. In 2018 the International Labour Organization estimated that about a billion people, one seventh of the world population, had disabilities, 80% of them in developing countries, and 80% of working age. Excluding disabled people from the workforce was reckoned to cost up to 7% of gross domestic product.

Afghanistan

After years of war in Afghanistan, there are more than 1 million disabled people. Afghanistan has one of the highest incidences of disabled people in the world. An estimated 80,000 Afghans are missing limbs, usually from landmine explosions.

Australia

More than 4 million people in Australia have some form of disability as of 2018. Approximately 18.6% of females and 18.0% of males are said to be affected. 50.7% of Australians aged 65 and over have disability, as opposed to 12.5% aged under 65.

United States

According to the U.S. Census Bureau, as of 2010, there were some 56.7 million disabled people, or 19% (by comparison, African Americans are the largest racial minority in the U.S., but only constitute 12.6% of the U.S. population).

Disabled individuals make up one of the most inclusive minority groups in the United States. According to the 2014 Disability status report of the Cornell University Yang Tan Institute the prevalence rate of individuals with disabilities in the United States was 12.6% in that year. As of 2014 ambulatory disability had the highest prevalence (7.1%) in the United States. By contrast, visual disability had the lowest prevalence (2.3%). Additionally, 3.6% of people in the United States were reported to have had an auditory disability in the same year.

5.8% of individuals ages 16–20 reported having any disability, physical and/ or cognitive. Adults 21 to 64 had a prevalence of 10.8% with over half of these (5.5%) being ambulatory disabilities. Ambulatory disability prevalence raised to 15.8% in adults 65–74 years of age. Adults 75 years and older comprised the highest prevalence with any disability at 50.3%. 

Female individuals across all ages reported a total 0.4% higher prevalence rate than males who reported 12.4%.

In the U.S. 17.9% of Native American peoples reported having a disability while 4.5% reporting were of Asian descent, these were the two opposing poles of the prevalence rate within race as of 2014.

Although there are acts that have been imposed in order to prevent the discrimination of individuals with disabilities in the workplace, there is still an employment gap that can be seen between those with and without disabilities. In regards to employment, the institute's status report accounts that 34.6% of people with any disability reported being employed. By comparison; 77.6% of individuals, who did not report having a disability, reported having a full-time job in 2014.

For those employed full-time, individuals with disabilities on average earned $5,100 less than employees without a disability who were also employed full-time. Those affected the most by these differences were intellectually disabled people. As of 2008, there were 2.9 million disabled veterans in the United States, an increase of 25 percent over 2001.

Europe

Nearly 8 million European men were permanently disabled in World War I. About 150,000 Vietnam veterans came home wounded, and at least 21,000 were permanently disabled.

Developing nations

There is widespread agreement among experts in the field, that disability is more common in developing than in developed nations. The connection between disability and poverty is thought to be part of a "vicious cycle" in which these constructs are mutually reinforcing.

Frailty syndrome

From Wikipedia, the free encyclopedia
 
Frailty syndrome
SpecialtyGeriatrics
A walker in the apartment of a senior woman
 
Frailty is a common geriatric syndrome that embodies an elevated risk of catastrophic declines in health and function among older adults. Frailty is a condition associated with ageing, and it has been recognized for centuries. As described by Shakespeare in As You Like It, "the sixth age shifts into the lean and slipper’d pantaloon, with spectacles on nose and pouch on side, his youthful hose well sav’d, a world too wide, for his shrunk shank…". The shrunk shank is a result of loss of muscle with aging. It is also a marker of a more widespread syndrome of frailty, with associated weakness, slowing, decreased energy, lower activity, and, when severe, unintended weight loss. 

As a population ages, a central focus of geriatricians and public health practitioners is to understand, and then beneficially intervene on, the factors and processes that put elders at such risk, especially the increased vulnerability to stressors (e.g. extremes of heat and cold, infection, injury, or even changes in medication) that characterizes many older adults.

Epidemiology

Frailty is a common geriatric syndrome. Estimates of frailty's prevalence in older populations may vary according to a number of factors, including the setting in which the prevalence is being estimated – e.g., nursing home (higher prevalence) vs. community (lower prevalence), and the operational definition used for defining frailty. Using the widely used frailty phenotype framework proposed by Fried et al. (2001), prevalence estimates of 7–16% have been reported in non-institutionalized, community-dwelling older adults. 

The occurrence of frailty increases incrementally with advancing age, and is more common in older women than men, and among those of lower socio-economic status. Frail older adults are at high risk for major adverse health outcomes, including disability, falls, institutionalization, hospitalization, and mortality. 

Epidemiologic research to date has led to the identification of a number of risk factors for frailty, including: (a) chronic diseases, such as cardiovascular disease, diabetes, chronic kidney disease, depression, and cognitive impairment; (b) physiologic impairments, such as activation of inflammation and coagulation systems, anemia, atherosclerosis, autonomic dysfunction, hormonal abnormalities, obesity, hypovitaminosis D in men, and environment-related factors such as life space and neighborhood characteristics. Advances about potentially modifiable risk factors for frailty now offer the basis for translational research effort aimed at prevention and treatment of frailty in older adults. A recent systematic review found that exercise interventions can increase muscle strength and improve physical function; however, results are inconsistent in frail older adults living in the community.

Theoretical understanding

Recent work on frailty has sought to characterize both the underlying changes in the body and the manifestations that make frailty recognizable. It is well-agreed upon that declines in physiologic reserves and resilience is the essence of being frail. Similarly, scientists agree that the risk of frailty increases with age and with the incidence of diseases. Beyond that, there is now strong evidence to support the theory that the development of frailty involves declines in energy production, energy utilization and repair systems in the body, resulting in declines in the function of many different physiological systems. This decline in multiple systems affects the normal complex adaptive behavior that is essential to health  and eventually results in frailty typically manifesting as a syndrome of a constellation of weakness, slowness, reduced activity, low energy and unintended weight loss. When most severe, i.e. when 3 or more of these manifestations are present, the individual is at a high risk of death.

Assessment of geriatric frailty

The syndrome of geriatric frailty is hypothesized to reflect impairments in the regulation of multiple physiologic systems, embodying a lack of resilience to physiologic challenges and thus elevated risk for a range of deleterious endpoints. Generally speaking, the empirical assessment of geriatric frailty in individuals seeks ultimately to capture this or related features, though distinct approaches to such assessment have been developed in the literature (see de Vries et al., 2011 for a comprehensive review).

Two key approaches are discussed below:

Linda Fried / Johns Hopkins Frailty Criteria

A popular approach to the assessment of geriatric frailty encompasses the assessment of five dimensions that are hypothesized to reflect systems whose impaired regulation underlies the syndrome. These five dimensions are:
  • unintentional weight loss,
  • exhaustion,
  • muscle weakness,
  • slowness while walking, and
  • low levels of activity.
Corresponding to these dimensions are five specific criteria indicating adverse functioning, which are implemented using a combination of self-reported and performance-based measures. Those who meet at least three of the criteria are defined as “frail”, while those not matching any of the five criteria are defined as “robust”. Additional work on the construct is done by Bandeen-Roche et al. (2006), though some of the exact criteria and measures differ (see Table 1 in the paper for this contrast). Other studies in the literature have also adopted the general approach of Linda P. Fried et al. (2001) though, again, the exact criteria and their particular measures may vary. This assessment approach was developed and refined by Fried and colleagues at the Johns Hopkins University’s Center on Aging and Health. This Center is home to Johns Hopkins Claude D. Pepper Older Americans Independence Center, which focuses on frailty research.

Rockwood Frailty Index

Another notable approach to the assessment of geriatric frailty (if not also to some degree its conceptualization) is that of Rockwood and Mitnitski (2007) in which frailty is viewed in terms of the number of health "deficits" that are manifest in the individual, leading to a continuous measure of frailty (see Rockwood, Andrew, and Mitnitski (2007) for a contrast of the two approaches). This approach was developed by Dr. Rockwood and colleagues at Dalhousie University.

Four domains of frailty

A four domains of frailty model was proposed in response to an article in the BMJ. This conceptualisation could be viewed as blending the phenotypic and index models. Researchers tested this model for signal in routinely collected hospital data, and then used this signal in the development of a frailty model, finding even predictive capability across 3 outcomes of care. In the care home setting, one study indicated that not all four domains of frailty were routinely assessed in residents, giving evidence to suggest that frailty may still primarily be viewed only in terms of physical health.

SHARE Frailty Index

The SHARE-Frailty Index (SHARE-FI) was originally developed by Romero-Ortuno (2010) (https://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-10-57) and researchers as part of the Survey of Healthy Ageing and Retirement in Europe. It consists of five domains of the frailty phenotype: •Fatigue •Loss of appetite •Grip strength •Functional difficulties •Physical activity.

The SHARE-FI calculator is freely available to use online. The calculator classifies individuals as 1) frail; 2) pre-frail; and 3) non-frail / robust. The SHARE-FI has good clinical utility as it provides relatively quick assessment of frailty in often time-poor healthcare settings.

Biological underpinnings

It has been suggested that the biological underpinnings of frailty are multifactorial, involving dysregulation across many physiological systems. A proinflammatory state, sarcopenia, anemia, relative deficiencies in anabolic hormones (androgens and growth hormone) and excess exposure to catabolic hormones (cortisol), insulin resistance, glucose levels, compromised altered immune function, micronutrient deficiencies and oxidative stress are each individually associated with a higher likelihood of frailty. Additional findings show that the risk of frailty increases with the number of dysregulated physiological systems in a nonlinear pattern, independent of chronic diseases and chronologic age, suggesting synergistic effects of individual abnormalities that on their own may be relatively mild. The clinical implication of this finding is that interventions that affect multiple systems may yield greater, synergistic benefits in prevention and treatment of frailty than interventions that affect only one system.

Associations between specific disease states are also associated with and frailty have also been observed, including cardiovascular disease, diabetes mellitus, chronic kidney disease and other diseases in which inflammation is prominent. To the extent that dysregulation across several physiologic systems underlie the pathogenesis of the frailty, specific disease states are likely concurrent manifestations of the underlying impaired physiologic function and regulation. It is possible that clinically measurable disease states can manifest themselves or be captured prior to the onset of frailty. No single disease state is necessary and sufficient for the pathogenesis of frailty, since many individuals with chronic diseases are not frail. Therefore, rather than being dependent on the presence of measurable diseases, frailty is an expression of a critical mass of physiologic impairments.

Components

Sarcopenia

Sarcopenia (from the Greek meaning "poverty of flesh") is the degenerative loss of skeletal muscle mass, quality, and strength associated with aging. The rate of muscle loss is dependent on exercise level, co-morbidities, nutrition and other factors. Sarcopenia can lead to reduction in functional status and cause significant disability from increased weakness. The muscle loss is related to changes in muscle synthesis signalling pathways although is incompletely understood. The cellular mechanisms are distinct from other types of muscle atrophy such as cachexia, in which muscle is degraded through cytokine-mediated degradation although both conditions may co-exist.

Osteoporosis

Osteoporosis causes a hunched-over appearance in some people.
 
Osteoporosis is an age-related disease of bone that leads to an increased risk of fracture. In osteoporosis the bone mineral density (BMD) is reduced, bone microarchitecture is disrupted, and the amount and variety of proteins in bone is altered. Osteoporosis is defined by the World Health Organization (WHO) in women as a bone mineral density 2.5 standard deviations below peak bone mass (20-year-old healthy female average) as measured by DXA; the term "established osteoporosis" includes the presence of a fragility fracture.

Osteoporosis is most common in women after menopause, when it is called postmenopausal osteoporosis, but may also develop in men, and may occur in anyone in the presence of particular hormonal disorders and other chronic diseases or as a result of medications, specifically glucocorticoids, when the disease is called steroid- or glucocorticoid-induced osteoporosis (SIOP or GIOP). Given its influence in the risk of fragility fracture, osteoporosis may significantly affect life expectancy and quality of life.

Muscle weakness

Muscle weakness, also known as muscle fatigue, (or "lack of strength") refers to the inability to exert force with one's skeletal muscles. Weakness often follows muscle atrophy and a decrease in activity, such as after a long bout of bedrest as a result of an illness. There is also a gradual onset of muscle weakness as a result of sarcopenia - the age-related loss of skeletal muscle.

Muscle weakness makes it difficult to perform everyday activities, like getting into a bathtub.
 
A test of strength is often used during a diagnosis of a muscular disorder before the etiology can be identified. Such etiology depends on the type of muscle weakness, which can be true or perceived as well as variable topically. True weakness is substantial, while perceived rather is a sensation of having to put more effort to do the same task. On the other hand, various topic locations for muscle weakness are central, neural and peripheral. Central muscle weakness is an overall exhaustion of the whole body, while peripheral weakness is an exhaustion of individual muscles. Neural weakness is somewhere between.

Healing power

Physical injuries heal slower and are more likely to leave permanent scars in older people. 

Aged people recover slower and are lesser likely to completely recover from physical injuries and accidents.

Surgical outcomes

Frail elderly people are at significant risk of post-surgical complications and the need for extended care. Frailty more than doubles the risk of morbidity and mortality from surgery and cardiovascular conditions. Assessment of older patients before elective surgeries can accurately predict the patients' recovery trajectories. The most widely used frailty scale consists of five items:
  • unintentional weight loss >4.5 kg in the past year
  • <20th centile="" for="" grip="" population="" span="" strength="">
  • self-reported exhaustion
  • low physical activity such that persons would only rarely undertake a short walk
  • slowed walking speed, defined as lowest population quartile on 4 minute walking test.
A healthy person scores 0; a very frail person scores 5. Compared to non-frail elderly people, people with intermediate frailty scores (2 or 3) are twice as likely to have post-surgical complications, spend 50% more time in the hospital, and are three times as likely to be discharged to a skilled nursing facility instead of to their own homes. Frail elderly patients (score of 4 or 5) have even worse outcomes, with the risk of being discharged to a nursing home rising to twenty times the rate for non-frail elderly people.

Ratlines (World War II aftermath)

From Wikipedia, the free encyclopedia
 
High-ranking fascists and Nazis who escaped Europe via the ratlines after World War II including: Ante Pavelić, Adolf Eichmann and Josef Mengele
 
"Ratlines" were a system of escape routes for Nazis and other fascists fleeing Europe in the aftermath of World War II. These escape routes mainly led toward havens in Latin America, particularly Argentina, Chile, Paraguay, Colombia, Brazil, Uruguay, Mexico, Guatemala, Ecuador, and Bolivia, as well as the United States and Switzerland.

There were two primary routes: the first went from Germany to Spain, then Argentina; the second from Germany to Rome to Genoa, then South America. The two routes developed independently but eventually came together. The ratlines were supported by clergy of the Catholic Church, and historian Michael Phayer claims this was supported by the Vatican.

While unanimously considered by reputable scholars to have committed suicide in Berlin near the end of the war, various conspiracy theories claim that Nazi leader Adolf Hitler survived the war and fled to Argentina.

Early Spanish ratlines

The origins of the first ratlines are connected to various developments in Vatican-Argentine relations before and during World War II. As early as 1942, Monsignor Luigi Maglione contacted Ambassador Llobet, inquiring as to the "willingness of the government of the Argentine Republic to apply its immigration law generously, in order to encourage at the opportune moment European Catholic immigrants to seek the necessary land and capital in our country". Afterwards, a German priest, Anton Weber, the head of the Rome-based Society of Saint Raphael, traveled to Portugal, continuing to Argentina, to lay the groundwork for future Catholic immigration; this was to be a route which fascist exiles would exploit. According to historian Michael Phayer, "this was the innocent origin of what would become the Vatican ratline".

Spain, not Rome, was the "first center of ratline activity that facilitated the escape of Nazi fascists," although the exodus itself was planned within the Vatican. Among the primary organizers were Charles Lescat, a French member of Action Française – an organization suppressed by Pope Pius XI and rehabilitated by Pope Pius XII – and Pierre Daye, a Belgian with contacts in the Spanish government. Lescat and Daye were the first to flee Europe with the help of Argentine cardinal Antonio Caggiano.

By 1946, there were hundreds of war criminals in Spain, and thousands of former Nazis and fascists. According to then-United States Secretary of State James F. Byrnes, Vatican cooperation in turning over these "asylum-seekers" was "negligible". According to Phayer, Pius XII "preferred to see fascist war criminals on board ships sailing to the New World rather than seeing them rotting in POW camps in zonal Germany". Unlike the Vatican emigration operation in Italy that centered on Vatican City, the ratlines of Spain, although "fostered by the Vatican," were relatively independent of the hierarchy of the Vatican Emigration Bureau.

Roman ratlines

Early efforts: Bishop Hudal

Bishop Alois Hudal, a Nazi sympathiser, was rector of the Pontificio Istituto Teutonico Santa Maria dell'Anima in Rome, a seminary for Austrian and German priests, and "Spiritual Director of the German People resident in Italy". After the end of the war in Italy, Hudal became active in ministering to German-speaking prisoners of war and internees then held in camps throughout Italy. In December 1944, the Vatican Secretariat of State received permission to appoint a representative to "visit the German-speaking civil internees in Italy", a job assigned to Hudal.

Hudal used this position to aid the escape of wanted Nazi war criminals, including Franz Stangl, commanding officer of Treblinka, Gustav Wagner, commanding officer of Sobibor, Alois Brunner, responsible for the Drancy internment camp near Paris and in charge of deportations in Slovakia to German concentration camps, and Adolf Eichmann—a fact about which he was later unashamedly open. Some of these wanted men were being held in internment camps: generally without identity papers, they would be enrolled in camp registers under false names. Other Nazis hid in Italy and sought Hudal out as his role in assisting escapes became known on the Nazi grapevine.

In his memoirs, Hudal said of his actions, "I thank God that He [allowed me] to visit and comfort many victims in their prisons and concentration camps and to help them escape with false identity papers." He explained that in his eyes:
The Allies' War against Germany was not a crusade, but the rivalry of economic complexes for whose victory they had been fighting. This so-called business ... used catchwords like democracy, race, religious liberty and Christianity as a bait for the masses. All these experiences were the reason why I felt duty bound after 1945 to devote my whole charitable work mainly to former National Socialists and Fascists, especially to so-called 'war criminals'.
According to Mark Aarons and John Loftus in their book Unholy Trinity, Hudal was the first Catholic priest to dedicate himself to establishing escape routes. Aarons and Loftus claim that Hudal provided the objects of his charity with money to help them escape and, more importantly, provided them with false papers, including identity documents issued by the Vatican Refugee Organisation (Pontificia Commissione di Assistenza). These Vatican papers were not full passports and thus were not enough to gain passage overseas. They were, rather, the first stop in a paper trail—they could be used to obtain a displaced person passport from the International Committee of the Red Cross (ICRC), which in turn could be used to apply for visas. In theory, the ICRC would perform background checks on passport applicants, but in practice the word of a priest or particularly a bishop would be good enough. According to statements collected by Austrian writer Gitta Sereny from a senior official of the Rome branch of the ICRC, Hudal could also use his position as a bishop to request papers from the ICRC "made out according to his specifications". Sereny's sources also revealed an active illicit trade in stolen and forged ICRC papers in Rome at the time.

According to declassified U.S. intelligence reports, Hudal was not the only priest helping Nazi escapees at this time. In the "La Vista Report" declassified in 1984, Counter Intelligence Corps (CIC) operative Vincent La Vista told how he had easily arranged for two bogus Hungarian refugees to get false ICRC documents with the help of a letter from a Father Joseph Gallov. Gallov, who ran a Vatican-sponsored charity for Hungarian refugees, asked no questions and wrote a letter to his "personal contact in the International Red Cross, who then issued the passports".

San Girolamo ratline

According to Aarons and Loftus, Hudal's private operation was small scale compared to what came later. The major Roman ratline was operated by a small, but influential network of Croatian priests, members of the Franciscan order, led by Father Krunoslav Draganović, who organized a highly sophisticated chain with headquarters at the San Girolamo degli Illirici Seminary College in Rome, but with links from Austria to the final embarcation point at the port of Genoa. The ratline initially focused on aiding members of the Croatian Ustaše including its leader (or Poglavnik), Ante Pavelić.

Priests active in the chain included: Fr. Vilim Cecelja, former Deputy Military Vicar to the Ustaše, based in Austria where many Ustashe and Nazi refugees remained in hiding; Fr. Dragutin Kamber, based at San Girolamo; Fr. Dominik Mandić, an official Vatican representative at San Girolamo and also "General Economist" or treasurer of the Franciscan order - who used this position to put the Franciscan press at the ratline's disposal; and Monsignor Karlo Petranović, based in Genoa. Vilim would make contact with those hiding in Austria and help them across the border to Italy; Kamber, Mandić and Draganović would find them lodgings, often in the monastery itself, while they arranged documentation; finally Draganović would phone Petranović in Genoa with the number of required berths on ships leaving for South America.

The operation of the Draganović ratline was an open secret among the intelligence and diplomatic communities in Rome. As early as August 1945, Allied commanders in Rome were asking questions about the use of San Girolamo as a "haven" for Ustaše.

A year later, a US State Department report of 12 July 1946 lists nine war criminals, including Albanians and Montenegrins as well as Croats, plus others "not actually sheltered in the COLLEGIUM ILLIRICUM [i.e., San Girolamo degli Illirici] but who otherwise enjoy Church support and protection." The British envoy to the Holy See, Sir D'Arcy Osborne, asked Domenico Tardini, a high-ranking Vatican official, for permission that would have allowed British military police to raid ex-territorial Vatican Institutions in Rome. Tardini declined and denied the church was sheltering war criminals.

In February 1947, CIC Special Agent Robert Clayton Mudd reported ten members of Pavelić's Ustaša cabinet living either in San Girolamo or in the Vatican itself. Mudd had infiltrated an agent into the monastery and confirmed that it was "honeycombed with cells of Ustashe operatives" guarded by "armed youths". Mudd reported:
It was further established that these Croats travel back and forth from the Vatican several times a week in a car with a chauffeur whose license plate bears the two initials CD, "Corpo Diplomatico". It issues forth from the Vatican and discharges its passengers inside the Monastery of San Geronimo. Subject to diplomatic immunity it is impossible to stop the car and discover who are its passengers.
Mudd's conclusion was the following:
DRAGANOVIC's sponsorship of these Croat Ustashes definitely links him up with the plan of the Vatican to shield these ex-Ustasha nationalists until such time as they are able to procure for them the proper documents to enable them to go to South America. The Vatican, undoubtedly banking on the strong anti-Communist feelings of these men, is endeavoring to infiltrate them into South America in any way possible to counteract the spread of Red doctrine. It has been reliably reported, for example that Dr. VRANCIC has already gone to South America and that Ante PAVELIC and General KREN are scheduled for an early departure to South America through Spain. All these operations are said to have been negotiated by DRAGANOVIC because of his influence in the Vatican.
The existence of Draganović's ratline has been supported by a highly respected historian of Vatican diplomacy, Fr. Robert Graham: "I've no doubt that Draganović was extremely active in syphoning off his Croatian Ustashe friends." Graham pointed out that Draganović, in running his 'ratline,' was not acting on behalf of the Vatican: "Just because he's a priest doesn't mean he represents the Vatican. It was his own operation." At the same time, there were four occasions in which the Vatican did intervene on behalf of interned Ustasha prisoners. The Secretariat of State asked the UK and US governments to release Croatian POWs from British internment camps in Italy.

U.S. intelligence involvement

If at first U.S. intelligence officers had been mere observers of the Draganović ratline, this changed in the summer of 1947. A now declassified U.S. Army intelligence report from 1950 sets out in detail the history of the people smuggling operation in the three years to follow.

According to the report, from this point on U.S. forces themselves had begun to use Draganović's established network to evacuate its own "visitors". As the report put it, these were "visitors who had been in the custody of the 430th CIC and completely processed in accordance with current directives and requirements, and whose continued residence in Austria constituted a security threat as well as a source of possible embarrassment to the Commanding General of USFA, since the Soviet Command had become aware that their presence in U.S. Zone of Austria and in some instances had requested the return of these persons to Soviet custody".

These were suspected war criminals from areas occupied by the Red Army which the U.S. was obliged to hand over for trial to the Soviets. The U.S. reputedly was reluctant to do so, partly due to a belief that fair trials could hardly be expected in the USSR, and at the same time, their desire to make use of Nazi scientists and other resources.

The deal with Draganović involved getting the visitors to Rome: "Dragonovich [sic] handled all phases of the operation after the defectees arrived in Rome, such as the procurement of IRO Italian and South American documents, visas, stamps, arrangements for disposition, land or sea, and notification of resettlement committees in foreign lands".

United States intelligence used these methods in order to get important Nazi scientists and military strategists, to the extent they had not already been claimed by the Soviet Union, to their own centres of military science in the US. Many Nazi scientists were employed by the U.S., retrieved in Operation Paperclip.

Argentine connection

In Nuremberg at that time something was taking place that I personally considered a disgrace and an unfortunate lesson for the future of humanity. I became certain that the Argentine people also considered the Nuremberg process a disgrace, unworthy of the victors, who behaved as if they hadn't been victorious. Now we realize that they [the Allies] deserved to lose the war.
Argentine president Juan Perón on the Nuremberg Trials of Nazi war criminals
1947 Rome issued ICRC travel document to a Croatian escaping Europe for Argentina.
 
In his 2002 book, The Real Odessa, Argentine researcher Uki Goñi used new access to the country's archives to show that Argentine diplomats and intelligence officers had, on Perón's instructions, vigorously encouraged Nazi and fascist war criminals to make their home in Argentina. According to Goñi, the Argentines not only collaborated with Draganović's ratline, they set up further ratlines of their own running through Scandinavia, Switzerland and Belgium

According to Goñi, Argentina's first move into Nazi smuggling was in January 1946, when Argentine bishop Antonio Caggiano, leader of the Argentine chapter of Catholic Action flew with another bishop, Agustín Barrére, to Rome where Caggiano was due to be anointed Cardinal. In Rome the Argentine bishops met with French Cardinal Eugène Tisserant, where they passed on a message (recorded in Argentina's diplomatic archives) that "the Government of the Argentine Republic was willing to receive French persons, whose political attitude during the recent war would expose them, should they return to France, to harsh measures and private revenge".

Over the spring of 1946, a number of French war criminals, fascists and Vichy officials made it from Italy to Argentina in the same way: they were issued passports by the Rome ICRC office; these were then stamped with Argentine tourist visas (the need for health certificates and return tickets was waived on Caggiano's recommendation). The first documented case of a French war criminal arriving in Buenos Aires was Émile Dewoitine, who was later sentenced in absentia to 20 years hard labour. He sailed first class on the same ship back with Cardinal Caggiano.

Shortly after this Argentinian Nazi smuggling became institutionalised, according to Goñi, when Perón's new government of February 1946 appointed anthropologist Santiago Peralta as Immigration Commissioner and former Ribbentrop agent Ludwig Freude as his intelligence chief. Goñi argues that these two then set up a "rescue team" of secret service agents and immigration "advisors", many of whom were themselves European war-criminals, with Argentine citizenship and employment.

In 2014, over 700 FBI documents were declassified revealing that the US government had undertaken an investigation in the late 1940s and 1950s as to the reports of the possible escape of Adolf Hitler from Germany. Some leads purported that he had not committed suicide in Berlin but had fled Germany in 1945, and eventually arrived in Argentina via Spain. Within the pages of these documents are statements, naming people and places involved in Hitler's alleged journey from Germany to South America including mention of the ratlines that were already in existence. Additional CIA documents contain reported sightings and a photograph of a man alleged to be Hitler in 1954. The claim related to the photograph made by a self-proclaimed former German SS trooper named Phillip Citroen that Hitler was still alive, and that he "left Colombia for Argentina around January 1955." Enclosed with the CIA report was the alleged photograph of Citroen and a person he claimed to be Hitler. The CIA report states that neither the contact who reported his conversations with Citroen, nor the CIA station was "in a position to give an intelligent evaluation of the information". The station chief's superiors told him that "enormous efforts could be expended on this matter with remote possibilities of establishing anything concrete", and the investigation was dropped.

ODESSA and the Gehlen Organization

The Italian and Argentine ratlines have only been confirmed relatively recently, mainly due to research in newly declassified archives. Until the work of Aarons and Loftus, and of Uki Goñi (2002), a common view was that ex-Nazis themselves, organised in secret networks, ran the escape routes alone. The most famous such network is ODESSA (Organisation of former SS members), founded in 1946 according to Simon Wiesenthal, which included SS-Obersturmbannführer Otto Skorzeny and Sturmbannführer Alfred Naujocks and, in Argentina, Rodolfo Freude. Alois Brunner, former commandant of Drancy internment camp near Paris, escaped to Rome, then Syria, by ODESSA. Brunner was thought to be the highest-ranking Nazi war criminal still alive as of 2007.

Persons claiming to represent ODESSA claimed responsibility for the unsuccessful July 9, 1979, car bombing in France aimed at Nazi hunters Serge and Beate Klarsfeld. According to Paul Manning, "eventually, over 10,000 former German military made it to South America along escape routes ODESSA and Deutsche Hilfsverein..."

Simon Wiesenthal, who advised Frederick Forsyth on the early 1970s novel/film script The Odessa File which brought the name to public attention, also names other Nazi escape organisations such as Spinne ("Spider") and Sechsgestirn ("Constellation of Six"). Wiesenthal describes these immediately after the war as Nazi cells based in areas of Austria where many Nazis had retreated and gone to ground. Wiesenthal claimed that the ODESSA network shepherded escapees to the Catholic ratlines in Rome (although he mentions only Hudal, not Draganović); or through a second route through France and into Francoist Spain.

ODESSA was supported by the Gehlen Organization, which employed many former Nazi party members, and was headed by Reinhard Gehlen, a former German Army intelligence officer employed post-war by the CIA. The Gehlen Organization became the nucleus of the BND German intelligence agency, directed by Reinhard Gehlen from its 1956 creation until 1968.

Ratline escapees

Some of the Nazis and war criminals who escaped using ratlines include:
  • Andrija Artuković, escaped to the United States; arrested in 1984 after decades of delay and extradited to Yugoslavia, where he died in 1988 from natural causes
  • Klaus Barbie, fled to Bolivia in 1951 with help from the United States, as he had been an agent of the U.S. Army Counterintelligence Corps since April 1947; captured in 1983; died in prison in France on September 23, 1991
  • Alois Brunner, fled to Syria in 1954; died around 2010
  • Herberts Cukurs, fled to Brazil in 1945, assassinated by Mossad in Uruguay in 1965.
  • Adolf Eichmann, fled to Argentina in 1950; captured 1960; executed in Israel on 1 June 1962
  • Aribert Heim, disappeared in 1962; most likely died in Egypt in 1992
  • Sándor Képíró, fled to Argentina, returned to Hungary in 1996. He stood trial for war crimes in Budapest in February 2011, before his death in September.
  • Josef Mengele, fled to Argentina in 1949, then to other countries; died in Brazil in 1979
  • Ante Pavelić, escaped to Argentina in 1948; died in Spain, in December 1959, of wounds sustained two years earlier in an assassination attempt
  • Erich Priebke, fled to Argentina in 1949; arrested 1994; died in 2013
  • Walter Rauff, escaped to Chile; never captured; died in 1984
  • Eduard Roschmann, escaped to Argentina in 1948; fled to Paraguay to avoid extradition and died there in 1977
  • Hans-Ulrich Rudel, fled to Argentina in 1948; started the "Kameradenwerk", a relief organization for Nazi criminals that helped fugitives escape
  • Dinko Sakic, fled to Argentina in 1947, arrested in 1998 and extradited to Croatia. He was tried and found guilty of war crimes and crimes against humanity, serving a 20 year sentence. He died in 2008.
  • Franz Stangl, fled to Brazil in 1951; arrested in 1967 and extradited to West Germany; died in 1971 of heart failure
  • Gustav Wagner, fled to Brazil in 1950; arrested 1978; committed suicide 1980

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