Introduction

The World Health Organization (WHO, 2011) estimated that 1 billion people, that is about 15% of the world’s population, live with disabilities, and one-fifth of them have significant impairments due to their conditions. An estimated 61 million or 26% of all adults in the United States live with a disability (Okoro et al., 2018). In the United States, the most common functional disability is serious difficulty walking or climbing stairs (13.7%), followed by cognitive disabilities (10.8%), hearing difficulties or deafness (5.9%), and blindness or vision (4.6%). Due to disabilities, 6.8% of adults have difficulty with independent living, and 3.7% are limited in their self-care, such as bathing or dressing (CDC, 2018).

Disability prevalence is higher in developing countries (Hosseinpoor et al., 2013). People with disabilities are more likely to experience adverse socioeconomic outcomes such as less education, poorer health outcomes, lower levels of employment, and higher poverty rates. In addition, many people with disabilities have underlying health needs that make them particularly vulnerable, including to contracting and experiencing severe impacts of COVID-19 (an infectious disease first reported in 2019 that became a worldwide pandemic in 2020) (WHO, n.d.a).

Disability can have many etiologies, including but not limited to disease, injuries, cognitive or emotional problems, or alcohol or drug misuse. Historically, disability has been defined as pathology contained within individuals. However, contemporary conceptualizations and measurement of disability have acknowledged environmental contexts, as well as the relevance of associated health conditions and their effects, on the functioning of those with underlying disorders (WHO, 2001). The International Classification of Functioning Disability (ICF) recognizes that individuals can have the same disorder and the same functional impairments, but different degrees of disability, depending on environmental context such as physical factors (e.g., climate, terrain, and/or building design) and social factors (e.g., attitudes, institutions, and/or laws). Considering the impact of larger systems on the functioning of individuals is consistent with the ecological perspective that governs social work practice.

The view that the impact of disability can vary significantly despite the existence of the same disorder or condition is gaining acceptance in the United States. The American Psychiatric Association (APA, 2013) urged the use of the World Health Organization Disability Assessment Schedule version 2.0 (WHODAS 2.0), an assessment tool based on the ICF framework, as an emerging measure for further research and clinical evaluation (see also Üstün et al., 2010). While disability may be related to medical or psychiatric disorders, the WHODAS 2.0 recognizes that personal and environment factors mitigate impairments, thereby necessitating the need to measure them separately from the etiological conditions which have caused them. Some studies have provided widespread support for this approach to assessing disability for clinical assessment and service eligibility with the WHODAS 2.0 translated into 47 languages and dialects and used in 27 areas of research (Federici et al., 2017; Garin et al., 2010; Marx et al., 2015).

As life expectancies increase and with technological advancements, the numbers and proportions of people living with disabilities will continue to expand. Thus, more social workers will be needed to work directly with this population. Additionally, all social workers must enhance their proficiency in addressing the needs of those with disabilities. Macro social work, which focuses on management and administration, community development and organization, and policy practice, will be essential to ensuring that those with disabilities maximize their independence and are afforded the same rights and opportunities as those without disabilities.

History

Throughout history, societies have attempted to explain the place of disability in the social order (Mackelprang, 2013). Neolithic tribes believed that disabilities were caused by spirits, and skull surgeries were performed to release spirits believed to be evil (Petrone et al., 2015). Ancient Greeks believed persons with disabilities were not human and that they should be abandoned to die (Plato, 1991; Stavrianos et al., 2018). Romans left children with severe disabilities to die and also used those with physical deformities for their own amusement (Trentin, 2011). Concomitantly, not all disabilities were problematic, particularly those that did not manifest with physical differences. For example, Julius Caesar had epilepsy, known as falling sickness, and claimed that he had visions during his seizures. In ancient Asia, disability was viewed similarly to that done in Western culture. Life with disability was viewed as substandard with people with disabilities often having to beg to meet their basic needs for survival. However, because religious vows of poverty were common in some parts of Asia, this activity was not stigmatized as it was in Western culture. Both heroic and malevolent characters with disabilities were featured in ancient Asian history (Miles, 2007). Contrarily, ancient Zoroastrian scripture dating back 2,500 years in Persia envisioned a perfect world without disabilities.

Judeo-Christian and Muslim histories portray disability negatively. The Koran displayed those who were deaf, blind, and “dumb” as being without understanding. The Old Testament forbade people with physical atypicalities and those of short stature from officiating in temple and priesthood ordinances. In the New Testament, blindness and other disabilities were believed to be caused by sins of those with these conditions or their parents. Those with erratic behavior, which would now be linked to mental illness, were thought to be possessed by devils (Espí Forcén & Espí Forcén, 2014). However, disability was not universally condemned. For example, both the Koran and the Bible describe Moses as having a significant speech impediment that did not disqualify him from leading the Israelites out of Egypt. The New Testament portrayed disability as arising from sin and spiritual deficiency. However, Jesus also displayed compassion for people with disabilities, setting an archetype for subsequent charitable efforts in Western culture.

In the Middle Ages, disability continued to be explained in religious and supernatural terms in which persons with disabilities were out of harmony with god or the natural order of the universe. However, although moral explanations prevailed during the Middle Ages, there was no singular, unifying perspective (Singer, 2012). When disability was attributed to demonic or evil influences, people were ostracized and killed. Many clergy espoused the belief that people with disabilities provided an opportunity for those without disabilities to display charity. People with leprosy were segregated to protect society physically and spiritually; however, some also believed lepers’ infirmities helped them to progress to salvation faster than others.

The Enlightenment era brought a new emphasis on rational inquiry that competed with morally-based explanations of disability. As early as 1600, Francis Bacon refuted the idea that “madness” resulted from moral punishment (Mackelprang, 2012). People with disability from birth were blamed for their conditions while those with disabilities acquired later in life were less stigmatized— these disparate views persist even today (Bogart et al., 2019). Those wounded in action were given special consideration and support. In Europe, people who were blind were especially afforded higher status resulting from the wartime practice in which prisoners of war were blinded by their captors and allowed to return to their homes. This practice was considered a humane alternative to execution while neutralizing the captives’ threat to the victors.

The Enlightenment coincided with industrialization and increased urbanization, all of which influenced societal reactions to disability. As scientific inquiry increasingly supplanted religious and supernatural explanations of disability, medical and rational explanations began to supersede moral explanations of disability. The rising reliance on medicine brought increased emphasis on curing, or at least treating, disabilities. Increasingly, people’s worth was measured by their ability to work and contribute to the economy. As contrasted to rural, agrarian societies, in which families and communities integrated those who were different, institutions that housed “the unproductive,” including people with disabilities, proliferated. Originally these congregate settings had the goal of segregating and confining those with disabilities who were viewed as dangerous to themselves or others as their conditions were incurable (Appleman, 2018). The number of people confined to institutions quickly rose, resulting in them serving as warehouses often with subhuman conditions.

The 1800s and the Victorian era brought increasing modernity and scientific advances. Charles Darwin’s observations challenged perceptions about the nature and development of humanity. Darwin observed that biological natural selection benefited species, whereas social Darwinists advocated eugenics, wherein social engineering would discourage undesirables from reproducing while promoting the proliferation of desired classes, primarily White, affluent people without disabilities (Appleman, 2018; Wiggam, 1924).

In the first half of the 20th century, both moral and medical approaches to explaining disability were firmly entrenched in Western culture. Disability was shameful, and people with disabilities were isolated. Professionals encouraged parents to institutionalize their children with disabilities. People with mental health problems were segregated in mental hospitals. People with mobility disabilities were denied access to public and private facilities. The United States’ Supreme Court decision in Buck v. Bell (274 U.S. 200, 1927) legitimized forced sterilization of people with disabilities by upholding a 1924 Virginia statute that allowed state governments to sterilize those who were deemed genetically unfit. This decision was one of the first times that the federal courts intervened in a case involving the rights of people with developmental disabilities, greatly limiting their rights by excluding them from protections afforded by the United States Constitution (U.S. Const. amend. VIII, XIX). Buck v. Bell paved the way for 30 other states to enforce similar laws, resulting in more than 60,000 men, women, and children in the United States being sterilized without their consent from the 1920s to the mid-1970s (Cohen, 2016).

Eugenics policies embedded in Western culture also provided impetus for the genocide of between 75,000 and 200,000 people with physical and/or cognitive disabilities in Nazi Germany. World War I produced hundreds of thousands of veterans and civilians with disabilities in Europe and the United States, and responses to their needs helped to shape the views of those with disabilities overall, with soldiers seen as worthy of treatment. Care of soldiers moved from provision of financial assistance, in the form of a pension and possibly custodial care in soldiers’ homes, to widespread conviction that the government should train and educate ex-service men so that they could return to productive lives (Rostker, 2013). Franklin D. Roosevelt was elected as President of the United States despite having a disability due to polio, though he went to great lengths to hide his physical limitations from the public. Increased survival rates of persons born with or acquiring disabilities, public responsibility to care for veterans disabled by wars, and technological advances led to increased awareness and attention to “treat” people with disabilities.

In the early decades of the 20th century, disability rights’ seeds were planted. The League of the Physically Handicapped was organized in the 1930s, to fight for employment during the Great Depression. In 1950, several local groups came together and formed the National Association for Retarded Children (NARC) (The Arc, n.d.). By the 1960s, the civil rights movement began to take shape, and disability advocates joined forces with those fighting for other minority groups to demand equal treatment, equal access, and equal opportunity. The Rehabilitation Act 1973 was passed in the United States, and for the first time in history, civil rights of people with disabilities were protected by federal law.

The Education for All Handicapped Children Act 1975 was passed to guarantee equal access to public education for children with disabilities. This legislation specified that every child had a right to education and mandated the full inclusion of children with disabilities in mainstream education classes unless a satisfactory level of education could not be achieved due to the nature of children’s disabilities. The Act was amended and renamed the Individuals with Disabilities Education Act (IDEA, 1990). The IDEA further promoted the inclusion of children with disabilities into regular classes and established the rights of parents to be involved in the educational decisions affecting their children. The IDEA required that Individual Education Plans (IEPs) be designed with parental approval to meet the educational needs of children with disabilities.

After decades of campaigning and lobbying, the Americans with Disabilities Act (ADA, 1990) was also passed, mandating equal treatment and access of people with disabilities to employment opportunities and to public accommodations. The ADA, inspired by the Civil Rights Act of 1964, prohibited discrimination in employment, services rendered by state and local governments, places of public accommodation, transportation, and telecommunications services based on disability status. President Obama signed the Workforce Innovation and Opportunity Act (WIOA, 2014) into law, which amended the Rehabilitation Act of 1973 to further stress full, competitive integrated employment for all people with disabilities and greater training for youth specifically.

Advances in technology are providing persons with disabilities new opportunities to participate fully in society. However, they still face significant social and economic problems. There remain barriers to employment, education, accessible and affordable housing, voting, and healthcare. Despite the passage of the ADA, deep-rooted assumptions and stereotypical biases continue to exist, resulting in ongoing prejudice toward and bias about people with disabilities. Current advocacy in the United States’ disability rights movement is primarily focused on empowerment and self-determination of people with disabilities. However, people with disabilities worldwide continue to face serious obstacles to humane treatment and realizing their rights on an equal basis with others. Current abuses such as violence, discrimination, segregation, and unlawful detention of people with disabilities worldwide is well documented (HRW, 2020).

In the future, social work as a profession must be at the forefront of advancing policies and services for those with disabilities given its ethical mandate of respecting difference and promoting equity and inclusion of those who are marginalized or oppressed. Macro social work will be particularly important as advocacy, mobilization, planning, development, and leadership in larger systems are needed to make critical structural changes that have prevented unequal treatment of and opportunities for those with disabilities in the past.

Social Work’s Commitment

Macro Social Work Practice: Protecting Rights and Enhancing Inclusion

A Look to the Future

Despite progress made toward advancing the treatment, views, and rights of people with disabilities, inadequate care, stereotypes, and discrimination still exist, even within the social work profession. For example, in October 2020, the Texas Board of Social Work Examiners voted unanimously, based on a recommendation from their Governor’s office, to change a section of its code of conduct that would allow social workers to refuse to serve others based on disability status, as well as sexual orientation or gender identity (Walters, 2020a). This action was highly criticized by the National Association of Social Workers and others as antithetical to the profession’s core values and principles (Walters, 2020b). Based on the outcry of social workers and other advocates, this decision was reversed two weeks later, but this incident highlights the need for social workers to stay vigilant in monitoring public policy to ensure that nondiscrimination protections are not removed.

The social work profession has a responsibility to promote equity and social justice. Social workers must continue to advocate for policies and practices that provide the same opportunities for all, regardless of cognitive or physical ability. The belief that rights of all are diminished when the rights of one are threatened remains as relevant today as it did more than 60 years ago during the civil rights movement (John F. Kennedy Library, 1963). The social work profession must partner with others to engage in social and political action to ensure existing protections for those with disabilities are not repealed and new legislations, regulations, and policies consider the supports needed to ensure that those with disabilities are able to fully participate. Central to all advocacy efforts must be the empowerment of those with disabilities. Social workers should embrace the slogan, “nothing about us, without us,” which was first used by disability advocates in the 1990s to stress that no decisions should be made about people with disabilities without their full and direct participation (Charlton, 1998). Social workers doing management and administration, community development and organization, and/or policy practice must ensure that people with disabilities are represented on decision-making bodies. Social workers must also promote policies and practices that maximize self-determination and self-directed service delivery systems.

Helping social work students with disabilities is a needed first step to obtaining greater representation of those with varying physical and cognitive abilities in the profession. Research shows that social work students with disabilities face challenges navigating college campuses and classrooms, as well as in their field settings (Sellmaier & Kim, 2020). Recent data reveals that some social work students experience ableist microaggressions and feel unsupported at times, as well as have an unfulfilled need for a disability-focused community within their programs (Kattari et al., 2020). Social work educators must develop tangible strategies to address these and other related problems to have more inclusive social work education. If social work programs cannot support students with disabilities, then who? If not now, then when?

Despite the importance of understanding the needs of individuals with disabilities, research indicates that disability content has been slow to be integrated into social work curricula, though most programs now have it infused into course content. A decade ago, data revealed that only 27%–37% of schools of social work included content on developmental disabilities in their curriculum (Laws et al., 2010). Analyses of course titles and descriptions indicated that this content was more likely to be infused in curricula rather than contained in dedicated courses (Bean & Krcek, 2012). Few, if any, undergraduate social work programs provide certificates in disabilities studies, and disability concentrations by graduate social work students are so infrequent that they are not even listed as an response option on surveys completed by accredited programs (CSWE, 2020; George Washington University, 2019). Additionally, social work curricula appear to be overly inclusive of a medical model of disabilities and not fully aligned with social work theory and values (Fuld, 2020). Assessment of social work curricula and revisions to future accreditation standards need to ensure that disability content is adequately covered and students can competently work with those with disabilities. Such competence requires getting more disability content into the core curriculum and development of disability specializations and certifications within undergraduate and graduate social work programs.

The recent United States’ federal election has highlighted Americans’ access to voting, a central right in any democracy (Levine, 2020). In assisting to eradicate the power dynamic which exists between those with and without disabilities, it is essential that social workers focus their social action efforts on removing barriers to voting for those with cognitive, physical, or other challenges. A recent report published by the United States Government Accountability Office found that 60% of polling locations had at least one impediment, such as steep ramps located outside buildings, lack of signs indicating accessible paths, and poor parking or path surfaces, which could deter individuals with mobility limitations from voting (GAO, 2017). Voter suppression has resulted in continued oppression and the maintenance of systemic social inequities within the United States. As one in four Americans has a disability, there are issues of access, equity, and representation which are universal across the diverse population of those with impairments. Social workers must focus their efforts on ensuring that people with disabilities have access to and exercise their right to vote to continue the path to building a just society with opportunities for all.