Forthcoming in: Cross-Cultural Rehabilitation: An International Perspective. R. Leavitt, Editor. London: W.B. Saunders Company (in press) DISABILITY CROSS-CULTURALLY Nora Ellen Groce, Ph.D Division of International Health Yale School of Public Health Introduction If rehabilitation professionals are to make a difference in the communities in which they work, it is essential that they understand and appreciate the complexity of health belief systems. These systems differ markedly from one culture to another and they tend to dictate how individuals with disability fare within their societies. Health belief systems also often dictate how, when and what type of rehabilitative care is made available to individuals with disability. Ideas about disability are part of a larger culturally based system of health beliefs and health behaviors. All cultures have shared ideas of what makes people sick, what makes people well and how people can maintain good health through time. These beliefs help people make sense of the world around them. Both lay people and health professionals tend to combine their society's health belief systems with knowledge gained through first hand experience. These individual models of belief are often referred to as explanatory models (Klienman 1980). Explanatory models provide a framework within which individuals sort through and make sense of illnesses, injuries and disabilities. Understanding the issue of health belief systems and individual explanatory models are important because there are few concepts of disability that are universally believed to be true. In fact, there are considerable differences in the way disability is regarded from one society to the next. Although disability tends to be viewed negatively in many societies, this is not always the case. Moreover, different types of disability tend to be regarded differently by members of the same society, hence an individual who has a vision impairment may be considered a full and active participant of a community, while in that same community an individual with mental health problems may be shunned. Understanding socio-cultural models of disability is of more than academic interest. Unless programs for individuals with disabilities are designed in a culturally-appropriate way, the opportunity to make real and effective change is often lost. This chapter is not intended to catalogue every known variation in disability beliefs, but rather to alert the practitioners to the fact that the ways in which disability and rehabilitation are conceptualized will have an impact on the manner in which rehabilitation professionals are received, regarded and able to serve their patients. Background There has yet to be a society found anywhere in the world that does not have a complex system of beliefs concerning disability. Universally, societies have explanations for why some individuals (and not others) are disabled, how individuals with disabilities are to be treated, what roles are appropriate (and inappropriate) for such individuals and what rights and responsibilities individuals with disability are either entitled to or denied (Scheer and Groce 1988). Rehabilitation professionals are too often trained to concentrate on clinical goals - restoring function in a specific set of muscles or training an individual in daily living skills, while ignoring the larger social networks and culture matrix in which those with whom they work, must live. Being aware of the weakness (and strengths) of the surrounding community, enables rehabilitation professionals to work far more effectively with and advocate in partnership with those whom they serve. It is important to note that there is still much that is not known about disability in society. The cross-cultural study of disability is less than a generation old. Although there are thousands of articles and books on rehabilitation, almost all of this research discusses disability in developed nations. Moreover, the bulk of this literature focuses on bio-medical factors rather than socio-cultural issues (Groce and Zola 1993). Yet it is estimated that 80% of all individuals with disability today live in the developing world, and of these 60-70% live in rural areas (Helander:1993). Hence it is anticipated that every year will bring us new information about how individuals and societies conceptualize and treat individuals with disabilities in different, and often unanticipated ways. Nevertheless, there is one clear conclusion that can be drawn even at this early date: the lives of individuals with disability around the globe are usually far more limited as a result of prevailing social, cultural and economic constraints than as a result of their specific physical, sensory, psychological or intellectual impairments. Beliefs about Disability: A Cross-Cultural Perspective A history of the field of rehabilitation usually begins with 19th or early 20th century pioneers, and a discussion of the rise of hospitals, clinics and institutions. It leaves the reader with the distinct impression that there were no provisions made for those with disability before the rise of professionals. In fact, individuals with disability have always been part of human society. Actually, the earliest evidence for an individual surviving with a significant disability, pre-dates humans. At Shanidar Cave in Iraq, a skeleton of an elderly Neanderthal shows that he survived for many years with a withered arm and blindness in one eye. Living into his 40's, elderly by Neanderthal standards, the man eventually died and his grave site was covered by his contemporaries with flowers, indicating that he was a valued member of that small social group (Solecki 1971). Archaeologists rarely find any skeletal population that does not have several individuals whose remains indicate some type of disability. Ancient art and pottery, early myths and legends from Greece and Rome, India, China and the Americas all show the presence of individuals with disability (Dashen 1993; Scheer and Groce 1988). Not only are individuals with disability found in all known societies, even more significantly, all known societies seem to have distinct ideas about how individuals with disabilities should be treated. What then can be said about disability in society cross-culturally? It might be best to begin by examining the idea of 'disability' itself. Although in English as in some other languages, a single term (disability) is used to refer to individuals with a wide range of physical, psychological or intellectual impairments, in many languages there is no one word to refer to such individuals. One can speak of "the blind" or "a deaf person" but the term "disability" which links all these people together in a single category may be missing, or little used. (Rengiil and Jarrow 1993; Scheer and Groce 1988). All societies do seem to recognize individuals with disability as having some physical, psychological or sensory attribute that distinguishes them from other non-disabled members of that society. Gallagher (1990) describes this as an "otherness." However it is the cultural interpretations of this "otherness" that is of concern and these cultural interpretations vary significantly from one society to the next. Moreover, disability categories used by western health professionals are not universal. Almost all societies have specific terms and conceptual categories for individuals who have moving difficulties; seeing difficulties; hearing and speech problems; learning difficulties; and seizure disorders. In addition, some cultures have developed specific categories of disability that are uniquely their own. There are a number of psychiatric disorders, known as cultural bound syndromes for example, that are unknown or rarely found in other cultures. Simons and Hughes (1985) list more than 150 of them. "Susto" for example, a condition believed to be caused by a sudden fright, is found widely in Latin America. A victim tends to become anxious and depressed, listless, and anoretic. Women tend to be affected far more frequently than men and in its most extreme form, it is believed to be fatal. Halatime and Berge (1990) found that in northern Mali, the most "disabling condition" for females, is to be ugly. There is widespread agreement of what physical attributes make a woman unattractive. Popular beliefs hold that a man who marries such a woman will loose a day of life for each day spent in such a marriage. Given the prevailing beliefs, marriage for such women is rare, and only married women have full social status in the community (Helander 1993). While not falling into a universal category of disability, these women's lives are nonetheless, severely restricted by a culturally defined 'disability.' Social Interpretations of Disability Societies do more than simply recognize disabling conditions in their members. They usually attach value and meaning to various types of disability. For the purposes of this discussion, these social beliefs will be grouped together in three categories that seem to regularly appear cross-culturally and which tend to allow one to predict how well an individual will fare in a given community and society: 1) Causality: the cultural explanations for why a disability occurs; 2) Valued and Devalued Attributes: specific physical or intellectual attributes are valued or devalued in a particular society; and 3) Anticipated Role: the role an individual with a disability is expected to play as an adult in a community. These are categories that should be familiar to rehabilitation professionals for they will be used as a basis upon which people's expectations and demands for (or avoidance of and passivity about) rehabilitation systems will be built.The beliefs associated with these three categories will effect individuals' willingness to receive care, and family and community willingness to support and encourage the individual who is receiving care. Additionally, these categories influence priorities, policy and a community's willingness to pay for care and services. Although there are many variations, the following is an overview of the more salient issues involved in each of the above categorizations. 1) Causality Societies treat individuals with disability well or poorly based in part on culturally based beliefs about why a disability occurs. Divine displeasure, witchcraft or evil spirits, reincarnation and biology are all given as the reasons why disability occurs in the ethnographic record (Scheer and Groce 1988). The birth of a child with a congenital defect is often considered a sign of divine displeasure with the child's parents or with the community. Disability which occurs later in life may also be considered a sign of divine displeasure with the individual who becomes disabled or is chronically ill. For example, disobedience to God's law was so strongly linked to disability in the Old Testament, individuals with disability were not allowed to approach the alter. In the New Testament, Christ upon restoring sight to the blind man, is reported to have said 'go and sin no more,' firmly tying the man's inability to see to the tradition of divine punishment (Gallagher 1990). Interestingly, the belief that God selects who will be disabled is not always negative. One study of Mexican-American parents found the belief that God wills a certain number of disabled children be born. Being merciful however, God chooses parents who will be particularly kind and protective for these "special" children (Madiros 1989). A similar finding is reported in Botswana, where the birth of a disabled child is viewed as evidence of God's trust in specific parents' ability (Ingstand 1988). The supernatural figure need not be a divine one. For example, marital infidelity on the part of the father (Ingstand 1990), or intercourse with too close a family member, a demon or an animal by the mother (Scheer and Groce 1988) are often cited as reasons why a disabled child is born. The belief that an offended witch or spirit has caused a child to be born disabled, or an adult to have a disabling accident, is widely reported from regions where witchcraft is a traditional explanation for ill health or misfortune. A victim of witchcraft is not always seen as an innocent victim. He or she may have done something to antagonize a spirit and the individual who is disabled is often avoided for fear that close association with such a person will put others at risk. Reincarnation, the belief that one's current physical and social state is a reflection of one's conduct in a previous life, often leaves individuals who are disabled in a particularly difficult situation. Their current status is seen as earned - and there may be less sympathy and less willingness to expend resources on their behalf. Not all societies believe the cause of disability is divine or supernatural. The idea that a disability can be 'caught' either by touch or by sight, is found widely. New brides and pregnant woman in particular, are discouraged from seeing, hearing or touching someone with a disability, for fear that they may give birth to a similarly disabled child. Examples can be found from Sri Lanka (Helander 1993) to the rural United States (Groce 1985; Newman 1969). This idea of contagion is so strong that some Native America parents continue to discourage their children from even touching assistive technology devises, such as wheelchairs (Thomason 1994). Similarly, in Kenya, huts for adults who are disabled are still built at some distance from the rest of the settlement, and utensils and other objects belonging to these individuals are not mixed with those of the rest of the family (Nicholls 1992). Modern medicine has redefined disability causation and looked for explanations in the natural world: genetic disorders, viruses and accidents are now commonly accepted as explanation for why one is born with or becomes disabled. But if modern medicine has replaced older causation concepts, it has often not done so completely. The idea of blame, inherent in most cultures for centuries often reappears in more 'scientific' forms. For example, if a child is born with a disabling condition, both professionals and lay people are quick to ask whether the mother smoked, drank or took drugs. If a young man is disabled in a car accident, many are anxious to know if he was driving too fast, or whether drugs or alcohol was involved. Some of these factors certainly can cause a disability to occur, but such inquires often go beyond simple scientific curiosity. What seems to occur is a resurfacing of the older need to determine whether the individuals thus effected, are in some way responsible for their current condition or the condition of their children. It has been hypothesized that part of this interest may be a psychological distancing - individuals try to establish a logical reason why a disability has occurred to reassure themselves that something similar will not happen to them. But another issue here is the continuation of the almost universal practice of determining causality in order to determine what demands the individual with a disability and that individual's family may justifiably make on existing social support networks and community resources. Sympathy and support is much more readily given to an individual whose disability is believed to be caused by a genetic anomaly, chronic illness, or random accident that, it is believed, could potentially affect anyone. Causality continues to be important even in the most modern of medical systems. For example, in the United States, someone in military combat who receives a severe spinal cord injury has access to far greater social, medical and economic supports than an individual with an identical injury who acquired it in a drunk driving accident. The deciding factor here is not the disability itself, but the specific circumstances surrounding the occurrence of the injury. Cultural explanations about causality are intriguing, but they must be used with some caution. Nkinyangi and Mbindyo (1982) doing work in Kenya, found that although witchcraft was regularly offered as an explanation, only 2% of their informants with disabilities believed that witchcraft was the reason why they themselves were disabled. In the Bahamas, although supernatural causes were traditionally associated with disability, today, that explanation is usually cited only to confirm the bad opinions about persons or families that were held prior to the onset of the disability (Goerdt 1989). Conversely, in the United States or Canada, parents may inform friends and relatives that their child has been born with a particular randomly occurring genetic syndrome, only to have these people speculate behind the parent's backs, about the possibility of maternal drinking or incest being present. Few societies have only one explanation of why a disability occurs. Rather, different types of disabling conditions are accounted for by different explanations. Profound deafness may be attributed to marital infidelity, whereas a disabled limb may be considered the result of personal 'bad luck' and 'fate.' 2) Valued and Devalued Attributes The underlying factors that determine how well an individual with a disability will fare in any given society, will depend not only on how that society believes a disability is caused, but also on what personal attributes a society finds important. Those individuals who are unable to demonstrate these attributes will be considered more severely disabled (Wolfensberger 1982). This will in turn be reflected both in the manner in which these individuals are treated as well as the society's willingness, or unwillingness to allocate resources to meet their needs. For example, in societies where physical strength and stamina are valued, those with significant physical disabilities are at a particular disadvantage. When one's status in the community depends in large measure on how well one can hunt or fish or farm, difficulty in walking or in lifting will diminish one's social status. Conversely, in a society where intellectual endeavors - the ability to work in an office or deliver a speech, is considered important, the fact that one uses a wheelchair or crutches to get around, will be far less significant. Factors will vary from one society to the next. For example, in many Native American groups, calling attention to oneself is considered improper. A valued attribute is to blend into the larger community rather than to stand out. Having a disability that automatically makes one stand out from one's peers, in such a community, is considered to be particularly stressful. In societies' willingness to allocate resources based on anticipated adult roles, disability issues often intersect with other social concerns, such as that of gender. The willingness of families to expend scarce resources on a girl with a disability might be substantially less for a comparably disabled boy. For example, in Nepal, although polio effects males and females in equal numbers, there are almost twice as many boys reported as disabled by polio as girls. At issue is not who gets polio, but who survives in the years following the illness (Helander 1993). 3) Anticipated Roles in Communities as Adults Finally, the willingness of any society to allocate resources for individuals with disability, including resources for rehabilitation efforts, will also depend in large measure on the anticipated role individuals with disability are anticipated to play in the community as an adult. At one extreme end of the continuum, a society might refuse to allocate any resources for those with disability and not allow them to live. Infanticide of even severely disabled newborns however, is exceptionally rare in the ethnographic literature (Scheer and Groce 1988). Only a small handful of groups seem to have regularly practiced it. Historically, in such cases, death is usually brought about by abandoning the infant on a remote hillside or cave shortly after birth. Smothering infants or otherwise causing death at the time of delivery has been reported in western midwifery, where families were usually informed that the child had been stillborn or died immediately following delivery (Helander 1993). In more recent years, the use of amniocentesis, genetic counseling, and the withholding of medical care in the delivery room, while touted as medical advances by some, are viewed by many disability activists as a more technologically sophisticated form of infanticide (Asch 1990; Hahn 1989). Even if infanticide were practiced on a regular basis, it would eliminate only a small percentage of all those having a disabling condition as most types of congenital disability, such as deafness or mild mental retardation, are not discernable in infancy, and accidents and chronic illness can occur at any point in the life cycle. The intentional killing of individuals with disability beyond the first two weeks of life, is all but unheard of in the ethnographic record. The killing of infirm or disabled elderly is reported from several societies, although it should be noted that such practices are quite rare and usually take place during periods of extreme hardship for the group as a whole, such as a time of food shortages, or exceptionally severe winters. Although there are isolated accounts of elderly infirm individuals being put to death for humanitarian reasons, the only known systematic elimination of disabled children and adults occurred in Germany during the Nazi era when, in an attempt to "purify" genetic stock, 300,000 German citizens with physical or psychiatric disorders - 85% of Germany's institutionalized population, were systematically put to death (Gallagher 1990). Renewed discussion of the 'right to die' and prolongation of life due to modern medical technology has stirred new debate on these issues around the subject of disability. While infanticide is rare, medical and physical neglect which results in death, are extremely common. It is not unusually in many countries for infants and children with disabilities to be "allowed" to die for want of food, medicines or other types of care that would be considered neglect if they were withheld from comparable non-disabled peers (Groce 1990). Predictions that such children and adults will not live long, nor be healthy can become self-fulfilling prophesy. Medical neglect can take many forms. Parents with limited resources may be slower to take their disabled child to a physician or healer should the child appear ill, hoping that the illness would clear on its own. They may be less willing to carry a disabled child several miles to ensure participation in the local immunization drive. Families that already have few resources may want to invest little in a child with a significant disability. The issue of social inclusion, over and above, inclusion in medical care, is a complex one. Survival is not the only measure of social attitudes. In some societies, individuals with disability are kept alive but hardly welcomed. In the Micronesian island of Paulau, someone with mental retardation is called "ultechei" which means "substitute" or "replacement," a less than-fully-human being. While such individuals are maintained within the kinship system, they are considered a burden on the family and community and their presence is not welcome (Rengiil and Jarrow 1993). It is not uncommon for individuals with significant disabilities to be considered a disgrace to the family, hidden from public view in the backroom or inner courtyard of a family house. This is particularly true in societies where disability is said to be caused by parental sin or God's displeasure. In some cases, while individuals with disability are valued within their own homes, they can anticipate no outside role in the community. They will be provided basic medical services, they will be feed, housed and cared for by relatives, but there is no provision made for their participation in society. Indeed, it is assumed that they will not want to or be able to participate in society. In such instances, educating these individuals, training them to earn a living, arranging for a marriage or even expending time and energy to locate medical and rehabilitative services for them, may be considered an unreasonable drain on a family's resources, particularly if such resources are very limited. Some have argued that in such societies an individual's inability to contribute to the family's economic needs, is the deciding factor in what status he or she maintains in the household and in the community. However, calculating a person's contribution in terms of formal employment, even marginal employment, outside the home, may be misleading. Many individuals with a disability who do not work outside their own homes or family units, do make significant contributions to their family's economic well-being. All but the most significantly disabled of individuals can contribute some work - they watch children, cook, clean and do housework and farm work, they help assemble parts for piecework or crafts brought to the marketplace in someone else's name. Indeed, they may be regularly assigned tasks that others do not want. Greene (1977) reported that rural families in Ecuador were concerned that newly introduced iodized salt would eliminate the birth of children with iodine deficiency syndrome. These children, born with hearing loss and mild mental retardation, were regularly given the task of herding animals, collecting firewood and drawing water. Who would do these onerous tasks, they asked, if such individuals were no longer born in their villages? Individuals with disabilities are often allowed partial inclusion in society. They are given limited roles and responsibilities. Specific roles for disabled individuals are often found, for example, blind people become, potters, broom makers, market vendors, and musicians in many cultures.By far the most common role assigned to individuals with disability however, is that of the beggar. Worldwide, the only role individuals with disability may have to support themselves and their families, is that of begging outside churches, temples and mosques, in marketplaces and railway stations. As Helander (1993) insightfully points out, for those who live in dire poverty, there is often little choice but to exploit their conditions. The more obvious the disability, the greater the chance of receiving alms. In such instances, rehabilitation may be avoided by some concerned that their improved physical abilities might lower their chances of feeding themselves and their families. More research is needed on this and many other issues that effect disability among the very poor. A full adult role in any community implies not simply employment, but the ability to marry and have a family of one's own, to decide where one will live, with whom one will associate and a voice in decisions made in the community. Although societies differ as to where, when and how individuals carry out these roles, a good rule of thumb for professionals evaluating the status of those with disability in any community, is whether such individuals are participating in such activities at a rate comparable to that of their non-disabled peers (ie individuals from comparable socio-economic and ethnic/minority backgrounds). In some societies, individuals with disability are given a special role. Used as symbols, they are sometimes believed to be particularly close to God, to bring or hold good luck, or that their existence satisfies evil spirits (Nicholls 1992). In some societies, individuals with disability are thought to be inspirational, and although ill treated on a day to day basis, at certain times of the year or on certain ceremonial occasions, they become the center of attention. (Christmas is such an example in the West). A special or reserved status is not, needless to say, necessarily an equal status. Full acceptance, that is, status and treatment comparable to one's non-disabled peers, is relatively rare, but it does exist and is important. For example, a number of tribal groups around the world such as the Azandi in East Africa and the Ponape of the Eastern Carolines in the southern Pacific, warrants comment because of their general kindness and acceptance of children born with obvious impairments (Gallagher 1990). Indeed, communities may interpret even significantly disabling conditions in a positive light. On the island of Martha's Vineyard, off the northeast coast of the United States, a gene for profound hereditary deafness led to the birth of a number of deaf individuals. Because deafness was so common, it was in the best interests of the hearing islanders to learn and use Sign Language and most did. With the substantial communications barrier - the very thing that most regularly blocks deaf individuals from full participation in society - breached, it is perhaps not surprising that deaf individuals on Martha's Vineyard, participated vigorously in the life of the small villages in which they lived. They were not considered to be (nor did they consider themselves to be) 'handicapped.' (Groce 1985) The fact that individuals with a disability assume roles comparable to all other members of a society is a good indication that real integration has been achieved. Obviously the more that the local health beliefs support the idea that individuals with disability are fully participating members of a community, the more demands may be placed upon rehabilitation professionals to assist such individuals. There may also be an opposite reaction. If a disabling condition is fully accepted and thought to be caused for a specific reason, (especially if it is thought to occur because of divine will), individuals and families may be less anxious to seek rehabilitation to eliminate traits which they do not perceive as a problem. Finally, the social role that an individual holds in society, may well change over time, as societies modernize. For example, in societies where most members live by manual labor, where people live by tilling the land or watching the flocks, many chores and jobs can be found for many who are mildly retarded. (Indeed, many who are severely retarded can also make significant contributions to their families and communities in such places). In technologically sophisticated societies, where all children are required to attend school for a number of years, it has become important to identify those children who fall below certain standardized test levels early. Once identified, these children are likely to be singled out from their peers. Their ability to compete in the work force as an adult is considered to be so compromised that in many countries, they are placed on a formal pension system at the age of 18 - a system that will maintain them for the remainder of their life. The difference here is not in the mental retardation of the individual, but in the socio-economic structure of the society into which he or she has been born. Why Rehabilitation Professionals Need to Understand Belief Systems The discussion about variation in the ways disability is conceptualized and dealt with cross-culturally is of more than passing importance for the rehabilitation professional. It has significance for virtually every part of the process of rehabilitation, from basic diagnosis, to treatment, to developing policy. Traditional diagnostic categories of disabling conditions, folk interpretations of the causes and consequences of living with a disability and willingness to follow prescribed medical and rehabilitative courses of action will all reflect local health belief systems. Even an action as simple as early childhood screening for disability and census taking to locate individuals with disability so planning can begin for rehabilitation programs, may be complicated by such belief systems. In many cultures where shame is attached to being disabled or having a disabled family member, reporting the presence of such an individual to the local health care provider or census taker may expose families to censure. When disability is connected with a sin or breaking a taboo, parents may not seek out early diagnosis and treatment in order to prevent drawing attention to that child or stigmatizing the family. Health Care Practices and Treatment Rehabilitation professionals must be cognizant of traditional medical systems and health seeking behaviors and recognizing that they often have much to offer. Not only is disability itself universal, but all societies have health care practices that in some way address various types of disabilities. There is often an inherent tension between traditional and modern medical practices, with practitioners from both groups advocating competition rather than cooperation. This is unfortunate. Traditional medical practices may be effective, ineffective, or ineffective in clinical terms, but of great benefit in psychological terms. A number of traditional folk practices, including messages and relaxation techniques, may be of great help to individuals with disabilities. (In fact, the National Institutes of Health in the United States has recently established a program to look specifically at what it calls 'Alterative Medicine" and to study the potential benefits of non-Western forms of medical care). In many cases, rehabilitation professionals might be well advised to try to combine the best of traditional and western techniques and practices. Patients are often already combining these practices, with or without the permission of their physicians and therapists. A survey of one of the largest and most modern rehabilitation hospitals in Indonesia revealed that over 85% of all those with physical disability were also making use of traditional healers or remedies. In many Native American communities, chronic illness and disability are seen as the outward manifestation of disharmony between the individual, the family or the community and the surrounding universe (Thomason 1994). In such instances, the issue to be first addressed is not the specific clinical or rehabilitative needs of the individual, but the restoration of some sort of harmony or balance between the individual and the surrounding universe, a process that can only be done by a traditional healer. Only after that are rehabilitation questions able to be dealt with. Decisions on whether to go to traditional healers or to seek help from western practitioners or clinics, or to combine the two forms of healing, will be based on a variety of factors. The type of disease or disability for which care is sought may be important, for some types of illness may be believed to be treatable by western medicine, others types may not. The availability and accessibility of care is equally as important. If rehabilitation programs require travel over considerable distances or if they are considered too costly, a local traditional practitioner may be sought out, even if western trained practitioners are believed to be more effective. Social networks also play an important role. If the local health practitioner is a cousin on whom you rely for financial aid in time of need, or who is responsible for helping you arrange the marriage of your son or daughter, or whose wife serves as the village midwife, going outside the community to seek help from a rehabilitation professional may seem unwise. In such a case, it is not that the rehabilitation professional has nothing to offer, but rather that in seeking care for one individual in your family, you have effectively severed important social support systems that reverberate throughout the rest of your family's social network. Furthermore, the need for clinical and rehabilitative services for those with disability will rarely exist in isolation from social needs, such as extreme poverty or lack of education. Therefore rehabilitation professionals must do more than simply deliver services in a clinical setting. They must take it upon themselves to learn what life is like in the community for the individuals they serve. Much can be learned by just talking (and listening) to individuals with disabilities and their families. Conclusion Individuals with disability can no longer be put at the end of a long list of competing social needs, such as basic education, clean water, sufficient food supplies or safe housing. Individuals with disabilities stand in as much need of the other social necessities as all other members of the community. Rehabilitation professionals, with an understanding of the socio-cultural ramifications of living with a disability, can contribute a great deal to this dialogue. For if prevailing social attitudes are not changed, much that rehabilitation professionals attempt to do will be fruitless. Extensive rehabilitation may allow a young woman with cerebral palsy to walk to the end of her street and back, but if she cannot do so without adults muttering insults and children throwing stones, not much has been accomplished. A cautionary note should be added here. There is often a tendency for policy makers, families and communities to turn to professionals for definitive word on systems of care and service for those with disability. It is vitally important to remember that those in rehabilitation should assist individuals with disability to represent their own claims in the community. They can help empower individuals with disability and their families to address and change traditional health beliefs and social attitudes, they should not become their voices. In urging rehabilitation professionals to bring people's attention to the potential of many with disability, it is imperative that they become familiar with traditional belief systems and health seeking behaviors. Culturally based beliefs about disability are often both strongly held and locally interpreted in a way one needs to understand in some detail before setting out to make changes. There have also been a number of successful adaptations to disability and there are without doubt many more as yet undocumented, that represent real strengths and provide decided advantages for disabled members of the community. In some communities, strong and supportive family structures, special roles and adaptations and a general acceptance of a specific type or types of disabilities, may provide a solid foundation upon which individuals with disabilities should build. Many of these adaptations might be quite local - specific to a small community or remote region. Even professionals in the nearby city or regional hospital may be unaware that they exist. Hence, community based rehabilitation workers need to ask what is traditionally done locally before they set out to make changes. Modernization and westernization can affect traditional health and disability beliefs and behaviors, but not necessarily dictate what old beliefs are retained, what new beliefs are added, or how the old and new belief systems will recombine. A new approach to disability may in fact, be no better than the more traditional belief systems. As traditional community supports dissolve with growing urbanization, individualization and a shift to a monetary economy, where the value of what a person is, is reflected by how much he or she can produce, the future is not necessarily clear nor bright. Therefore attempts to introduce new ides by rehabilitation professionals must be carefully monitored. 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