Triple jeopardy: disabled people and the COVID-19 pandemic

People with disabilities have been differentially affected by COVID-19 because of three factors: the increased risk of poor outcomes from the disease itself, reduced access to routine health care and rehabilitation, and the adverse social impacts of efforts to mitigate the pandemic. 10 years ago, WHO's World Report on Disability noted that people with disabilities were more likely to be older, poorer, experience comorbidities, and be female.¹ Older age, deprivation, and comorbidities are also associated with increased risk of severe outcomes from COVID-19.² Risk of death from COVID-19 between Jan 24 and Nov 30, 2020, in England was 3·1 times greater for men with disabilities and 3·5 times greater for women with disabilities than for men and women without disabilities.³ People with intellectual disabilities living in congregate residential settings, relevant mainly to high-income settings, had a higher risk of death from COVID-19 than people without disabilities.4, 5 But even in household settings,⁶ people with intellectual disability have an increased risk of COVID-19 death.⁷

Worldwide, disasters and emergencies often disproportionately impact the disability community, and this pandemic is no exception.8, 9, 10 People with disabilities have faced many barriers to inclusion in the COVID-19 response (panel ). The lockdown measures societies have taken during the COVID-19 pandemic have meant people with disabilities are worse off and more excluded.¹¹ If lockdown and curfew are enforced through aggressive actions by security forces, as in some countries in southern Africa, then people with disabilities who may need to access health care or pharmacies are penalised. Cancellation or postponement of regular health care or rehabilitation will differentially impact those with additional health needs.10, 12 When assistive technology is not prescribed, maintained, or repaired, people with disabilities are rendered dependent. When social care is put on hold, cancelled, or reduced, people with disabilities are thrown back on the support of families if they have them. When it is not possible to attend day centres or voluntary projects, people with disabilities may be left with no one to meet.¹³ When individuals are expected to use face masks and physically distance, people with hearing loss who cannot lip read or people with visual impairment who use guide dogs can find it difficult to follow these rules and as a result they might be stigmatised. Additionally, confinement in homes increases the risk of physical or sexual violence and abuse, to which children and adults with disabilities are additionally vulnerable.14, 15

Panel. Barriers to inclusion of people with disabilities in the COVID-19 response.

• •Failure to ensure safety of people with disabilities in congregate living or health facilities
• •Failure to ensure access for people with disabilities to: food deliveries; internet; COVID-19 testing; and water, sanitation, and hygiene facilities
• •Failure to give relevant people with disabilities or their families or support workers evidence-based priority for COVID-19 vaccination or COVID-19 treatment where required
• •Lack of or inadequate support for people with disabilities living alone or where family members or support workers are self-isolating or affected by COVID-19
• •Unclear public health messaging or lack of accessible messaging
• •Postponement of required medical treatment, including rehabilitation
• •Failure to collect data on disability to allow disaggregation

Inadequate preparedness for the impacts of the COVID-19 pandemic on people with disabilities has been shockingly familiar. People with disabilities have been overlooked or are an afterthought in the education provision for children with special educational needs,9, 12, 16 the provision of personal protective equipment in social care,4, 5, 6 or the inclusion of sign language in government announcements. In Uganda, school closures have led to the exclusion of many young people with disabilities since educational materials are not in accessible formats and access to assistive technology, including the internet, has been a challenge.

In a public health crisis such as the COVID-19 pandemic, clear information becomes more important than ever. In the UK, messages have been confused or complicated, which has been difficult for people with intellectual disabilities to understand. In other countries, there can be low confidence in public health messaging.¹⁷ Increased isolation and uncertainty or fear about the pandemic have also impacted the mental health of people with disabilities. People with mental illness can find isolation and fear particularly debilitating.18, 19 People with physical impairments are also disproportionately at risk of mental health conditions.²⁰ For many people, this pandemic has generally been bad for mental health.18, 19

Yet in the pandemic there have been some positive developments for people with disabilities. Where they can get internet access, people with disabilities have been able to participate in society as never before, because physical and communication barriers have largely disappeared as education, work, shopping, and many leisure activities have been driven online.²¹ Moreover, there are reassuring signs in some places that people are looking out for each other more, often replacing the dominant individualism of high-income settings with neighbourliness and mutual aid. People with disabilities do much better in societies with strong social protections and where people support each other.²²

However, participation—whether digital or in person—typically requires financial and other resources. The economic shocks of this pandemic particularly impact the poorest in society, who are often old, disabled, or female. About 80% of the poorest people with disabilities live in low-income and middle-income countries, where there is either inadequate social safety protections or no welfare state.¹ The consequence is that people with disabilities often have to rely on families or charity.

People with disabilities do not want a return to the pre-pandemic status quo, which was a world filled with complex barriers to inclusion, especially in low-income and middle-income countries. The COVID-19 pandemic has increased risks, compounded unmet health needs, and disproportionately affected the socioeconomic lives of people with disabilities around the world. As evidence evolves, strategic thinking is needed about how society, social inclusion, and public health can better reach the 15% of the global population¹ who are disabled. The inclusion of people with disabilities in the COVID-19 response should be remembered throughout all post-recovery stages by assessing their needs and ensuring that they are consulted and can participate in policy development, programme design, and implementation. A better future has to grow from learning the lessons, listening to the life experiences of people with disabilities, and making meaningful investments that improve the wellbeing and socioeconomic conditions of people with disabilities.