Disability and mortality in LMICs: why we need to know more
Authors: Nora Ellen Groce
Journal: The Lancet Global Health (2024)

In global health, there is a major difference between assuming something is true and bringing together and analysing the data to provide a clear picture or confirm long-held assumptions. An example of the effort to move from assumption to data-based fact is reflected in the paper by Tracey Smythe and Hanna Kuper,1Smythe T Kuper H The association between disability and all-cause mortality in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2024; 12: e756-e770Google Scholar who conduct a systematic review and meta-analysis of mortality rates among people with disabilities in 22 low-income and middle-income countries (LMICs). Smythe and Kuper's findings represent an important addition to the literature. There is a great need for more systematic reviews and meta-analyses of data related to the health and wellbeing of people with disabilities. In fact, the study of disabled populations on all levels is a crucial, but still far too often overlooked, component of global health and international development.2WHO/World BankWorld Report on Disability 2011.https://www.who.int/disabilities/world_report/2011/report/en/Date: 2011Date accessed: August 7, 2023Google Scholar There is relatively little research on people with disabilities, who are often discussed as an afterthought, if discussed at all. There are also few large-scale quantitative comparative studies on any component of disability,3UNUnited Nations Flagship Report on Disability and Sustainable Development Goals.https://www.un.org/development/desa/disabilities/publication-disability-sdgs.html#:~:text=%E2%80%9CThe%20UN%20Flagship%20Report%20on,can%20create%20a%20more%20inclusiveDate: 2018Date accessed: March 25, 2024Google Scholar yet more than 1·3 billion people live with a disability, which equates to 16% of the world's population. One household in every four has a disabled member.4WHO and London School of Hygiene and Tropical MedicineThe missing billion: access to health services for 1 billion people with disabilities.https://www.lshtm.ac.uk/TheMissingBillionDate: 2021Date accessed: March 21, 2024Google Scholar No global health issue will be solved if we continue to overlook this substantial part of humanity. Mortality rates of people living with a disability are not well understood. It has long been assumed that people with disabilities are at increased risk of ill health and early death, and it is often stated that this is particularly true in LMICs, where health care and public health interventions are often less available or effective.3UNUnited Nations Flagship Report on Disability and Sustainable Development Goals.https://www.un.org/development/desa/disabilities/publication-disability-sdgs.html#:~:text=%E2%80%9CThe%20UN%20Flagship%20Report%20on,can%20create%20a%20more%20inclusiveDate: 2018Date accessed: March 25, 2024Google Scholar However, actual data are rare, and comparative data are rarer still; in light of this, this large and thoughtful study on mortality rates of people living with a disability in 22 LMICs represents an important addition to the literature. The authors present two key findings. First, conducting a solid meta-analysis of mortality among people with disabilities, the authors' systematic review included more than 6000 publications. The authors identified, reviewed, and analysed 70 data-based studies from 22 countries on mortality rates among people with disabilities, and concluded that disability increases the risk of all-cause mortality in LMICs. This conclusion moves the global discourse on disability and health forward. Second, only 70 studies, with a range of different sample sizes, were found after an exhaustive search, highlighting a major gap in the global literature. The continued scarcity of research on mortality rates of people with disabilities in LMICs means that many more data-driven studies are needed. The authors identify whole regions of the world where little or no data on mortality rates have been published. Readers should pay close attention to where these gaps are and consider how they might contribute to new research to fill in the blanks. An important issue to raise is that no single paper can solve all the issues. The meta-analysis here shows a link between disability and mortality in LMICs, but it does not tell us why. It is too often assumed that higher rates of mortality exist among people with disabilities due to poor health or chronic conditions linked to their disabilities. However, a growing body of research has begun to show that the frequent assumption that people with disabilities are in poor health becomes a self-fulfilling prophecy. A person with a disability who does not receive equal access to health services and is not included in public health initiatives is at higher risk of morbidity and mortality than someone without a disability. This effect has little to do with that person's disability and a great deal to do with the discrimination, withholding of resources, and lack of understanding of what it means to live with a disability. This issue is compounded by the fact that millions of people with disabilities face social, cultural, and economic barriers. Disproportionate rates of poverty among people with disabilities are the result of inequalities in access to education, employment, sociocultural inclusion, housing, nutrition, transportation, and greater risk in times of emergency and disasters,3UNUnited Nations Flagship Report on Disability and Sustainable Development Goals.https://www.un.org/development/desa/disabilities/publication-disability-sdgs.html#:~:text=%E2%80%9CThe%20UN%20Flagship%20Report%20on,can%20create%20a%20more%20inclusiveDate: 2018Date accessed: March 25, 2024Google Scholar, 4WHO and London School of Hygiene and Tropical MedicineThe missing billion: access to health services for 1 billion people with disabilities.https://www.lshtm.ac.uk/TheMissingBillionDate: 2021Date accessed: March 21, 2024Google Scholar all of which are linked to increased rates of morbidity and mortality. This issue does not only affect LMICs. In the UK, 24% of people live with a disability, but 59% of people who died during the COVID-19 pandemic were people with disabilities.5Office of National StatisticsUpdated estimates of coronavirus (COVID-19) related deaths by disability status, England: 24 January 2020 to 9 March 2022.https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/coronaviruscovid19relateddeathsbydisabilitystatusenglandandwales/24january2020to9march2022Date: 2022Date accessed: March 21, 2024Google Scholar Many of these deaths related to social, financial, and medical decisions—such as being considered a lower priority for ventilators—rather than to their disability.6The Health FoundationThe forgotten crisis: exploring the disproportionate impact of the pandemic on disabled people.https://www.health.org.uk/news-and-comment/blogs/the-forgotten-crisis-exploring-the-disproportionate-impact-of-the-pandemicDate: 2021Date accessed: March 21, 2024Google Scholar For all these reasons, Smythe and Kuper's paper represents an important step forward, providing both new insights and a potential road map for next steps in asking—and answering—key questions about mortality among people with disabilities in LMICs. I declare no competing interests. The association between disability and all-cause mortality in low-income and middle-income countries: a systematic review and meta-analysisPeople with disabilities had a two-fold higher mortality rate than people without disabilities in LMICs. Interventions are needed to improve the health of people with disabilities and reduce their higher mortality rate. Full-Text PDF Open Access