Impact of COVID-19 on People with Disabilities

Any condition of the body or mind that makes it more difficult for the person with the condition to do certain activities and interact with the world around them is known as a disability. Despite the various efforts being made to ensure the rights and equity of the disabled, they still suffer more during crises like conflicts, natural disasters, and pandemics. The purpose of this narrative review is to assess the impact that the COVID-19 pandemic has had on people with disabilities (PWD). For writing this narrative review, Google, Google Scholar, PubMed and online news portals were searched by using various combination of the following terminologies; “Disability”, “Differently abled’, “Disabled”, “People with Disabilities”, “PWD” “Impact”, “COVID-19”, “Corona Pandemic”, “Challenges”, “Issues”, “Policies”, “Social”, and “increased risk”. The pandemic has created many challenges for PWD. They not only have greater risk of contracting COVID-19, but also have difficulty accessing health services and suffer from various social problems. The COVID-19 pandemic has exposed gaps in the health system that make the poor, marginalized and disabled population more vulnerable to neglect and mistreatment. Governments should make sure that the policies made to protect the rights of the disabled are implemented properly and take strict actions whenever there is failure to do so. It is important to continually integrate PWD into the mainstream society while minimizing their risks of contracting COVID-19. The caretakers should use the necessary PPE when attending to their needs. It should be ensured that PWD feel included and respected.


INTRODUCTION
Any condition of the body or mind that makes it more difficult for the person with the condition to do certain activities and interact with the world around them is known as a disability. 1 Even though people with disabilities (PWD) are usually classified under the same umbrella, it is very diverse and comprises a wide range of people with varying needs. The concept of disability is complex and constantly evolving. Traditionally, disability has been seen only as a medical condition with focus on only medical diagnosis and its treatment. 2 However, in recent years a concept of social model of disability has emerged. This model focuses on the differences between impairment and disability and tries to highlight the impact of social factors on disability. 2 Along with social, physical barriers are also found to play a vital role in disability. 3 The International Classification of Functioning, Disability and Health (ICF) has divided disability into three different dimensions: impairment, activity limitation, and participation restrictions. 4 It is estimated that approximately one billion people had some form of disability globally in 2018 4 and the rates are on the rise due to the increase in ageing population and chronic health conditions. 4 United Nations Economic and Social Commission for Asia and the Pacific, reported that the prevalence of disability in New Zealand was 24%, while in Pakistan, India and Nepal it was 2.5%, 2.2%, and 1.9% respectively. 2 Nonetheless, the prevalence in different countries may not reveal the true disability rate owing to varying definitions that are used worldwide. 2 People with disability (PWD) already suffer from different challenges in life because of their medical state and the way they interact with people or their surroundings. Even in normal circumstances, they have higher probability of living with poverty, and are more likely to face violence, abandonment and mistreatment. 5 This situation has been exacerbated by the COVID-19 pandemic. Despite the various efforts being done to ensure their rights and equity, they still suffer more during various crises like conflicts, natural disasters, and pandemics. This occurs due to the unavailability of or disruption of health services, support groups, rehabilitation services, employment opportunities, etc. 6,7 The purpose of this narrative review is to assess the impact that the COVID-19 pandemic has had on PWD.

MATERIALS AND METHODS
For writing this narrative review, Google, Google Scholar, PubMed, and online news portals were searched by using various combination of the following terms "Disability", "Differently abled", "Disabled", "People with Disabilities", "PWD" "Impact", "COVID-19", "Corona Pandemic", "Challenges", "Issues", "Policies", "Social", and "Increased Risk". We screened all the articles that we found from the search, with the aim of including articles that had information about PWD and the various challenges that they faced during COVID-19 pandemic. Next, we acquired the full text of the potential articles and used the articles that met our criteria for writing the review. The duration of writing of the article was 2 months.

Greater risk of contracting COVID-19
Some PWD may be at a higher risk of contracting COVID-19. 8 Various factors may contribute to this threat. 8,9 First, the risk is increased because of decreased access to personal protective equipment such as face masks, and hygiene kits. 9 People with mental and physical disabilities may not be able to wash their hands even if there is availability of water and soap. Because of their ailments, some of them are not able to turn on a tap and wash their hands independently. In addition, persons with special needs may not be able to maintain physical distance without support from others. For some disabled people, touching of objects may be required for physical support or to get information, which raises the risk. 9 Second, their disability may cause barriers in accessing public health information for COVID-19 prevention, 9 or prevent them from communicating their symptoms. 8 For example, individuals who are blind or have impaired vision cannot access information provided as charts or graphs. 10 Similarly, the health instructions provided via television will not be understood by deaf people if it is not reinforced by captioning or by sign language interpreters. 10 In addition, disabled adults are at three times higher risk than those without disabilities to have diseases like cardiac disease, stroke, diabetes, or cancer, 8 and preexisting history of chronic diseases is associated with a higher risk of severe illness from COVID-19. 8 They may also be at higher risk of contracting the illness and may have graver outcomes, as a result of their living situation. A study conducted in California, USA, among individuals with intellectual and developmental disability illustrated that the outcomes of COVID-19 were bleaker for those living in congregate living settings when compared to the general population. 11 Similarly, data from Emergencies Working Group in Nigeria showed that PWD, who lived in slums or emergency settlements areas were in danger of contacting COVID-19 disease. 12 The main reason attributed in both situations is overcrowding, and the lack of proper physical distancing. 11,12 The situation is even worse for children living with disabilities. In particular, children with problems in hearing, seeing and cognitive functioning, encounter difficulties in accessing important public health information regarding control and prevention of COVID-19 pandemic. 13 Additionally, they are likely to be living in financial paucity and have limited capacities, which limits their access to (Water, Sanitation and Hygiene) WASH facilities and makes them vulnerable to infective diseases like COVID-19. 13

Decreased access to health services
One of the most common challenges faced by PWD is decreased access to healthcare despite having greater healthcare needs than other people. United Nation's assessment of 43 countries showed that, more people with disabilities (42%) perceive their health as poor when compared with those without disabilities (6 %). 14 During the current COVID-19 pandemic, people with disability have suffered profoundly as the scale of the crisis created by the pandemic has far surpassed the response capability of governments and other service providers. A survey in UK showed that, about 50% of its disabled population needing regular medical care had decreased access to healthcare (i.e. only getting partial treatment or cancelled treatments) since the COVID-19 pandemic began. 15 However only 27% of those without disability had the same problem. 15 Similarly, a rapid review conducted among people with physical disability, to assess the impact on their lives due to the pandemic, showed that they faced multiple problems due to the decrease in the provision of health facilities. 16 While some of them had trouble getting their regular medication, others suffered due to lack of availability of ambulances and transportation to reach health facilities, and also interruption of physiotherapy sessions at home. 16 Some PWD needing specific medical services on a daily basis have suffered due to closure of or reduction in capacity of rehabilitation centers. 17, 18 In addition, others have suffered due to the change in modality of treatment like the use of telemedicine. Even though telemedicine has proven to be very effective during the lockdown in order to provide treatment while maintaining physical distancing, it poses many challenges for PWD. 19 For the blind, deaf or those with cognitive disabilities, there may be barriers to accessing the service or understanding the instructions of physicians. 19

Discrimination and loneliness
Disability is already associated with a certain degree of discrimination. In the light of the COVID-19 pandemic, the instances of discriminatory acts against the disabled have increased further. PWD have had to face negative attitude, neglect and stigmatization during this crisis. 20 Despite being against the fundamental right to healthcare, people with disability have had to deal with discrimination due to medical rationing for management of COVID-19. 10 This is the result of triage guidelines which have exclusion criteria based on various kinds of impairments, people needing high support on a daily basis, those with decreased chances of success of treatment along with considerations of "life-years" of survival. 21 Furthermore, many family members of PWD have also faced pressure within the health system to renounce resuscitation measures. 21 Additionally, according to an analysis of three-year data from the England Community Life Survey (CLS) 2016 to 2019, PWD are shown to experience higher degree of seclusion, decreased perceived social support and separation, when compared with people without disability. 22 The prolonged lockdown and social distancing as a result of the pandemic has added to this, and PWD have had to face increased loneliness and isolation. 17,23 A survey in Ireland showed that solitude and fear were the most important issues for many PWD. 17 Moreover, some of them said that they were angry and could not grasp what was going on. 17 With the closure of rehab centers, day care centers and schools, PWD have lacked social interaction and a support network. This has added to the already present stress due to the pandemic.

Employment related problems
People worldwide have lost jobs because of the pandemic. According to the ILO report published in 2020, closure of workplaces around the world has disrupted employment globally leading to loss in working hours that are much greater than was estimated. 7 A report in March 2021 showed that the unemployment increased dramatically in the USA in April 2020, with the disabled having higher percentage of unemployment compared to those without any disability. 24 Likewise, several cases have been reported in India where families with disabled members have suffered during COVID-19. 25 While some of them have been released from their employment contracts, others with jobs could not get to their work places due to the halt of public transportation during the lockdown. 25 Similarly, many have not been paid their salaries citing business losses. 25 These factors have led to financial insecurities and difficulty in meeting basic needs like food and medical supplies. 25

Education related problems
Disabled students have suffered immensely during the pandemic. 26,27 Shifting of educational activities to the online system may not be ideal or inclusive for these pupils. First, such students will not get adequate help from qualified educators. 28 In addition, a change in classroom setting may also present as a barrier to such students. Face-to-face classes provided students with a safe place to interact and learn, and also offered their families with support. 29 But the virtual classroom is devoid of these facilities. Moreover, with virtual classrooms extra time and resources are necessary for active participation of disabled pupils, which increases the expenses incurred on their education. 21 In the United Kingdom, many have voiced difficulty in accessing online classes during the pandemic and several have complained regarding lack of alternative teaching materials. 26 The results of a survey among 4000 students showed that more than a quarter of them were unable to access online lectures. 26 Hundreds of them also reached out to the disabled student helpline citing lack of access to reading materials (slides, handouts etc.) before classes, 26 which acts as an added barrier to their education. The situation is similar in the United States of America (USA), where the transition from classroom learning to online forum has been a challenge to many disabled students and their parents. 27 There are reports where college students who are blind have contacted National Federation of the Blind mentioning difficulty with the shift to virtual classroom teaching. 30 They complained mainly of incompatibility between their learning materials and their screen readers (which helps them read and navigate documents). 30 According to the CEO of the National Association of the Deaf, students who are deaf or hard-of-hearing may also face challenges due to the lack of sign language interpreters or real-time captioning during online classes. 30 For children with intellectual or learning disabilities and their parents, this pandemic has been even more challenging. Results of a qualitative study done in two states of USA, among parents having young children with disabilities, showed that many parents were concerned about longstanding effects of COVID-19 on their offspring's development. given the loss of services, education and social engagement opportunities. 31

Plans, Policies and Way Forward
There is an urgent need to take actions to guarantee that PWD have access to public health information, to health-care services, and WASH services as required on a daily basis. 9 It is more important in crisis situations like the current COVID-19 pandemic. These people are already stigmatized and marginalized by the community due to their disabilities and the pandemic has increased their vulnerability to further inequalities. Various international agencies have worked for the disabled and done work that focuses on the urgent need to be inclusive while planning for disaster situations like the COVID-19 pandemic.
An article of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) requires that countries take all necessary measures for ensuring rights of PWD in the national response to health emergencies like the current pandemic. 32 This encompasses measures which include provision for general wellbeing and highest attainable standard of health without discrimination, protection against negative attitudes, isolation, and stigmatization associated with the pandemic. 32 As these clauses are legally binding, execution of these obligations will safeguard rights of persons with disabilities. 32 The new ILO brief points out what needs to be done to make the socio-economic response inclusive of persons with disabilities and also addresses issues related to containment measures and the long-term recovery. 7 It proposes making workplace disability friendly by providing disability inclusive occupational safety and health measures for  It also states that PWD should also be considered while planning alternative work setting during the pandemic. This may be specifically important while having a virtual work environment in which disabled employees may need extra support like, use of sign language or access to certain software that may aid their adjustments to the online work space. 7 The brief further discusses about the need of support for disabled people in keeping their old jobs or in getting new ones. In this context, in Bangladesh, the disability network has been helping by providing matching services between employers and potential disabled employees. 33 Similarly, the Philippines business and disability network has started training PWD with skills required to adapt to job openings during the pandemic. 33 Additionally, the ILO brief also adds about the need of targeted social protection measures for the disabled like the provision for added allowances during the pandemic along with help in kind. 20 Similarly, WHO has also released a report addressing the issues that need to be thought of while considering effect of COVID-19 on the PWD. It discusses various courses of action for actors at household level, for the government and community members, as well as considerations for disability service providers and health workers. 34 At household level care should be taken to reduce the disabled members' exposure to COVID-19 and the household should be prepared for treatment of such patients in case they get ill. 34 Likewise, the community should provide a helpful environment for PWD and their families. This can include easy access to stores, supportive environment at work and help from neighbours. 34 Similarly, governments should make sure that the public health information regarding COVID-19 is accessible to PWD. 34 They should also make sure that there is availability of support networks or helplines for the disabled during the crisis. Additionally, COVID-19 health care should be made accessible, affordable and inclusive, with preference to telehealth for the disabled. 34 Furthermore, those involved in providing care to the disabled should have a plan to continue services during such public health emergencies. 34 Many countries have already implemented these policies and have established an example for others, while others are yet to implement the changes. 20 Several nations like India, Jordan and Morocco have established hotlines for helping the disabled during COVID-19. 20 Others have added monetary support for the disabled on top of the compensation that they are already getting. 20 Additionally, many PWD have received assistance in the form of food aid and supply of daily essentials needed for sanitation. 20

CONCLUSION
The COVID pandemic has exposed gaps in the health system that make the poor, marginalized and disabled population more vulnerable to neglect and mistreatment. It has also taught the world many things, especially in public health. This global crisis has presented an opportunity to be creative and commit to more inclusive and universal health plans and policies. While in many countries such policies already exist, it has been implemented only in a few. In some nations, ignorance and lack of inclusive policies have led to PWD being mistreated and neglected. Hence, states need to make sure that the protection of the rights of the disabled are given utmost priority. Proper implementation and monitoring of policies should be done to ensure that PWD feel included and respected. It is important to continually integrate PWD into the mainstream society while minimizing their risks of contracting COVID-19. The caretakers should use the necessary PPE when attending to their needs.