Description

Disabilities include long-term sensory, mental, intellectual, or physical impairments that can impact people's daily lives, health care, and support needs. The prevalence of disabilities will most certainly increase substantially in the coming decades as the global population ages. Nonetheless, people with disabilities are often neglected by health systems and experience profound inequalities in health and wellbeing outcomes. What role does public health have in tackling these inequalities?

Population interventions can reduce health lost to some disabilities by addressing immediate causes, such as through improving work safety or reducing road accidents. In some cases, expanding access to secondary prevention could reduce years lived with disability. More than 1 billion people worldwide have some form of visual impairment, including 41 million people who are blind, and yet 90% of visual impairment is preventable or treatable in a cost-effective way. Hearing loss is one of the leading contributors to years lived with disability, affecting 1•57 billion people; expanding screening and treatment could substantially reduce the direct health burden of hearing loss, and educational disadvantage among children with hearing loss and the risk of social isolation among older adults.

Many disabilities are not preventable, however. People living with disabilities face poorer overall health outcomes than their peers without disability. The Missing Billion Report on access to health services for the billion people with disabilities found evidence from a range of countries that people with disabilities have a higher prevalence of conditions such as diabetes, cardiovascular disease, preterm birth, HIV, childhood malnutrition, and substance misuse. Disabilities interact with comorbid conditions and exposure to social determinants of ill-health to produce these health disadvantages.

Health Care

People with disabilities are often excluded through direct and indirect discrimination from the workforce and from education. According to WHO, half of all people with disability are unable to afford health-care, compared with a third of people without disabilities? People with disability commonly face barriers such as lack of transportation, inaccessible health-care facilities and non-disability-friendly equipment or procedures. Health-care providers too often lack the skills to meet the specific needs of people with disabilities or general awareness training to ensure that people are treated well and fairly. Health-care workers may fail to look past a person's disability to see other, unrelated health-care needs. These barriers can also exclude people with disabilities from preventive health activities ranging from cancer screening and access to sanitation to the simple opportunity for physical exercise.

The COVID-19 pandemic has laid bare the inequalities around disability. Mortality rates have been high among people with disabilities and quality of life has been disproportionately impacted by interruptions to regular health and community services, and the need to self-isolate. In this issue of The Lancet Public Health, Andrew Steptoe and Giorgio Di Gessa report that older people with disability in England experienced greater symptoms of depression, anxiety, and loneliness during the COVID-19 lockdown than their peers without disability. During the pandemic, while some positive initiatives to prioritise people with disabilities were made, such as the vaccination prioritisation dashboard in the USA described by Sabrina Epstein and colleagues’ Correspondence, the underlying health injustice faced by people with disabilities has worsened. The COVID-19 pandemic further shows that health and social care systems are ill-prepared to support people with disabilities during international health or humanitarian crises.

Building back fairer after the pandemic offers an opportunity to rethink and end the neglect of people with disabilities in public health this will be essential to meet the sustainable development goal ambition to leave no one behind. For Bonnie Swenor, “Until people with disabilities are included in all efforts to advance health equity, we will fall short in reaching this goal.” As a first step, better data on the health inequalities facing people with disabilities are urgently needed to understand the epidemiology of disability and related social determinants of health. Moreover, disability awareness should be included in the curricula for those working in and researching health. Disability should no longer be an afterthought and needs to be included in all public health equity efforts.

Gambling involves placing something of value at risk in the hopes of gaining something of greater value, and includes casino gambling, lotteries, and internet gambling. Gambling is not an ordinary activity: It is a health-harming addictive behaviour, recently recognised in the International Classification of Diseases 11th Revision (ICD-11) and Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5). Gambling disorders often remain undiagnosed and untreated. According to WHO, the prevalence of gambling disorders among adults varies between 0•1% and 5•8%. Gambling is a source of potentially serious and wide-ranging harms, affecting an individual's health, wealth, and relationships. It affects whole families and communities, and can become a lifelong struggle to avoid relapse. There is an urgent need to assess and understand the barriers and facilitators to preventing gambling-related health harms.

The rapid and geographically broad increase in use of internet and smartphones has completely altered the gambling landscape. Today, the possible adverse effects of the COVID-19 pandemic on addictive behaviours and disorders are yet to be fully understood. The COVID-19 pandemic response, bringing lockdowns and unprecedented restrictions in people's lives, could act as a catalyst, intensifying gambling behaviours by increasing time spent at home and time spent online. Preliminary data from a survey of 6000 respondents in China suggest that coping behaviours during the COVID-19 crisis increased the risk for substance use disorders and internet addiction.

An awareness of this growing public health issue could provide an opportunity to ensure public support to tackle gambling-related harms and protect the most vulnerable. In this issue of The Lancet Public Health, Heather Wardle and Sally McManus report results from a survey in young adults aged 16-24 years showing an association between gambling behaviour and suicidality (suicidal thoughts and suicide attempts). As Charles Livinsgtone and Angela Rintoul note in an accompanying Comment,”In view of these data, it is crucial to improve screening and support services for people with gambling problems, either within primary care or in addiction treatment settings”.