Disability Studies Quarterly Winter 2009, Volume 29, No.1 <www.dsq-sds.org> Copyright 2009 by the Society for Disability Studies

Introduction

Reviewing scholarship on the complex relationships between disability and poverty present in Bangladesh's economy, micro-finance industry, community-based rehabilitation programs (CBR), and poverty reduction strategy papers (PRSP) and laws, I explore how perspectives about disability exacerbated the problems and further disadvantaged people labeled with disabilities. Throughout history, many have and continue to use medical models as their way of comprehending disability, impairment, and cognitive, physical, or sensory difference. One of the most widely disseminated definitions of disability, The World Health Organization's (WHO) International Classification of Impairments, Disabilities, and Handicaps (ICIDH), is such a medical model. In the ICIDH, disability is defined as, "any restriction or inability (resulting from an impairment) to perform an activity in the manner or within the range considered normal for a human being" (World Health Organization, 1992, p. 34). In medical models, disabilities are descriptions of disturbances in function at the level of the person that are relative to norms and whose practitioners operate through culturally dominant discursive practices. Quite differently, the social model lacks clinical categories and instead, focuses on culture and context. In the social model, disability as a social construct is a floating signifier, whose meaning and impact are felt by social actors (Hall, 1996). From this perspective, categories such as race, class, gender, and disability change due to time and place.

When disability is viewed as a social construct, the analysis is not about the individual but the community they live in and the normative interpretations of bodily difference that dominate it (Gallagher, 2003). The social model of disability enables a focus on a cultural and contextual level where "disability is a form of social oppression involving the social imposition of restrictions of activity on people with impairments and socially engendered undermining of their psycho-emotional well-being" (Thomas and Corker, 2002, p.19). How one is valued is greater than their physical state and, "this prejudice is not just interpersonal, it is also implicit in cultural representation, in language and in socialization" (Shakespeare, 1994, pp. 296). Differences among people are a reality in the social model, however, our realities revolve around the culturally ascribed dominate meanings of differences and how they irrevocably impact lives (Gallagher, 2001).

Another issue to consider is how poverty is defined and how it shapes perspectives. The Direct Calorie Intake (DCI) method, Food Energy Intake (FEI) method, and Cost of Basic Needs (CBN) method have all been used by private and government researchers to study poverty in Bangladesh. The Bangladesh Bureau of Statistics, with assistance from the World Bank, utilized the CBN method on the Household Expenditure Survey to measure and analyze poverty in 1995/6. In the CBN method, the poverty line is defined as the sum of the food poverty line, the monthly cost to meet the caloric requirement, and the non-food poverty line, the minimum expenditure to meet basic needs (Japan Bank, 2001). In the DCI and FEI methods deal only with caloric intake and do not factor in other costs to meet basic needs. Sometimes it can be misleading to find a poverty level that is only taking daily food requirements into account. While ones' perspective on disability or poverty can wildly vary, most of the general board economic indicators on Bangladesh are on the upswing.

Economic growth

Over the past two decades, Bangladesh has made positive gains with poverty and infrastructure. For instance, there were increases in non-farm income, from 42% in 1988 to 56% in 2004, and per capita income (Cherdchuchai and Otsuka, 2006). Poverty is in decline, an analysis of poverty rates from 1991 to 2000 in Bangladesh demonstrate a marked decrease in rural areas, 53% to 44%, and urban areas, 34% to 26% (Sen, 2003). Moreover, in the past decade there have been improvements in the markets, health care, less internal political strife, and public work projects on infrastructure. For example, in 2000, Bangladesh was second only to Sri Lanka in lowest infant and under-five mortality in a regional comparison that included: Bhutan, India, Maldives, and Nepal (Grant, Hulme, Moore, & Shepherd, 2004). Yet, with over half of GDP generated through the services sector, nearly two-thirds of those employed are in the agricultural sector (Nationmaster, 2008). Regardless of disability, the move from the farm to non-farm sectors of employment is impossible without, "the acquisition of financial and human capital to apply the know-how of a new livelihood strategy" (Nargis and Mahabub, 2006, p.434). Solutions to these problems are complex. In part, we have to collectively consider how the context of discrimination against those labeled with disabilities and their family members negates broad based programs intended for the impoverished.

Historically, national statistics on the prevalence of disability in Bangladesh are a contentious issue. While some low rates, from 0.64% to 1.6%, were purported by the government based on surveys in 1982, 1986, and 1998, more recent estimates from Action-Aid Bangladesh, Bangladesh Protibandhi Kallayan Samity, and Social Assistance and Rehabilitation for the Physically Vulnerable estimate 7.8% to 8.8% (Alam, 2005). In terms of the contexts where people labeled with disabilities live, a recent study approximates that 80% reside in rural areas, "and over 50% labeled with impairments that could be prevented and impacted by poverty past CBR efforts in Bangladesh dealt with a confluence of issues such as "poor nutrition, limited access to health care, natural disasters, and cultural discrimination" (Alam, Bari, and Khan, 2005, p. 3). With over 100 million rural inhabitants (Sundquist, 2008), districts such as Chuadanga, a primarily agricultural rural district in the Khulna Division, provide low income employment, lack of fiscal resources and a general lack of support from non-governmental organizations and government agencies. In 2006, Chuadanga had a population of 1,007,130 people (Bangladesh Bureau of Statistics, 2006). A baseline survey by Impact Foundation Bangladesh in Chuadanga of 4,528 households revealed a disability prevalence of 5.7% (IFB, 1997). Of the 256 households with one or more members labeled with a disability, 61 per cent had less than 0.2 ha compared to over sixty percent of their peers who had more than 1.ha (IFB, 1997).

In developing countries such as Bangladesh, the lack of formal state-provided services often forces people to seek help in social networks (Momin, 2001). These networks provide crucial emotional and practical support and, additionally, facilitate access to formal services, if there are any. Being part of such networks is essential, especially in situations of sudden illness, natural disasters, or accidents (Momin, 2001). The absence of social connections makes it far more difficult to break away from poverty and ill health (Barry, 1998).

While recent broad national economic trends are positive, the plight of those labeled with disabilities and as poor remains bleak. For instance, in a long ranging study of Bangladesh's economic development over the past thirty years, Haque (2007) notes, "when we look at the distribution of income in terms of income shares at the top and bottom deciles, their quotient and differences and the Gini index, we found the income distribution in Bangladesh has worsened with the progress of economic development" (p. 32). The disparity in wealth between rich and poor is growing. Rural areas in Bangladesh that depend on the agricultural industry for employment such as Chuadanga have precarious poverty rates, which were highlighted in the late 1990s. Overall, for these regions the poverty rates increased in 1996 and 1998 because of flood damage and decreased in 1999 in many rural areas due to bountiful harvests (Japan Bank, 2001). This differs from economic opportunities in urban districts such as garment factories, which increased from four in 1978 to 2,400 in 1995 employing 1.2 million workers, 90% of whom are females (Amin, 2002).

The past contexts for the majority of people labeled with disabilities is undergoing change, with the current rate of urbanization one-third of Bangladesh's population will live in urban areas by 2010 (Amin, 2002). The urban sprawl will impact the informal economy. It is estimated that the informal sector or employment ranges from 80 to 90% of total national employment in Bangladesh with it being less in heavily populated areas such as Dhaka (Amin, 2002). Finally, even though the economy has annually increased from 5 to 6% during the past few years, impediments to growth included: floods, cyclones, inadequate port facilities, insufficient power supplies and a rapidly growing workforce that is outpacing employment in the agricultural sector (Nationmaster, 2008). Like the recent explosive growth of urbanization, the rise of micro-finance in Bangladesh has unforeseen outcomes for people labeled with disabilities.

Micro-finance

Micro-credit lenders exponentially increased in Bangladesh with more than 1,000 opening since 1990 and offering interest rates from 10% to 30% (Chowdhury & Wright, 2005). The schemes work on a peer-group basis with delivery systems such as the Bangladesh Rural Advancement Committee (BRAC) and the Association of Social Advancement (ASA). Often, defaulting on loans by any member is the responsibility of the entire group (Johnson and Rogaly 1997; Thomas, 2000). Two studies, Lewis and Sygall (1997) in Tanzaniz and Malawi and Chowdhury and Foley (2006) in Chuadanga found limited to no access to micro-finance for study participants who were labelled with a disability or had an immediate family member labelled with a disability. In Chuadanga, only 8 per cent of women labelled with disabilities are members of credit-providing non-governmental organizations compared with 90 per cent of their peers (Chowdhury & Foley, 2006). Although Bangladesh in the past thirty years has increased per-capita income and decreased percentage of population below the poverty line and family size, there are still groups, such as women labelled with disabilities or with family members with disabilities who, due to discrimination and stigma, who cannot access one of the largest lending sources in their country (Haque, 2007).

It remains a concern that some micro-credit providers fail to further investigate this issue and they, in turn, continue to exclude women labelled with disabilities, even though this group, along with other highly impoverished and vulnerable people, is supposedly a prime focus of their work. Others have noted concerns over the effectiveness of some micro-finance programs to aid the impoverished. For instance, a recent analysis on a BARC micro-finance program and its effectiveness in enabling lenders out of poverty found a statistically insignificant difference between those who were funded 63.6% over their peers who received no funding, 61.2% (Hoque, 2004). Although BARC is attempting to empower women through forming lending groups, Dilruba (2002) found their income as inadequate and irregular because of low return activities. Citing a lack of purposeful spending, Hoque (2004) proposes closer supervision of marketing micro-finance programs to promote investment in income generating activities and making the loans larger for entrepreneurial endeavours. Within the agriculture industry, Sen (2003) notes that crop intensification and agricultural diversification aid some in escaping poverty through developing a combination of assets; however, when people are denied access for micro-finance money or the knowledge on how to best utilize the funds, some efforts appear to ignore why, in part, the suffering occurs.

Community-Based Rehabilitation Programs

Developed by the World Health Organization as a primary health care approach (Mitchell, 1999), CBR is a multi-faceted tool, "for improving service delivery in order to reach all in need, for providing more equal opportunities find form promoting and protecting the human rights of disabled people" (Helander, 1993, p. 8). In a 2003 report, McLeod argues that the World Bank should continue to finance CBR because past programs: have demonstrated positive gains in development; are cost effective compared to more traditional means of assistance; increase the access of those in greatest needs to services; and are in growing demand worldwide. CBR began in Bangladesh in the late 1980s with the majority of the programs being disability focused, serving urban areas, and bearing theoretical orientations that "saw disability more from [a] medical rehabilitation perspective rather than the social development model" (Alam, Bari, and Khan, 2005, p. 5). These disconnects between medical classifications and models in dealing with individualized impairment to the neglect of stigma, discrimination and other cultural barriers was not only an issue for the early days of CBR in Bangladesh. In a literature review of CBR studies throughout the world, Cheausuwantavee (2007) cites lack of empowerment, rights, equal opportunities and social inclusion of people labeled with disabilities. Often the CBR projects reviewed were run by people from outside of the community, "without consideration towards community concerns and participation" (Cheausuwantavee, 2007, p. 103).

On a global scale, the role of Disabled People's Organizations (DPO), especially cross-disability organizations and single-disability organizations, within CBR has increased with some influencing political leaders and others providing advisement (World Health Organization, 2004). Historically, DPO's community level efforts have received less funding than political efforts to sway gatekeepers (Coleridge, 2007). Noting how CBRs need to be concerned with developing positive identities on the individual level while also being an aware and politcal advocate of their rights, Kendall, Buys and Larner (2000) state these goals are only accomplishable in tandem. Further elaborating this concern Alam, Bari, and Khan (2005) advocate for a CBR program that promotes positive attitudes about people labeled with disabilities and provide rehabilitation, education and training services. Over the past thirty years, the roles and responsibilities of CBR in Bangladesh have paradigmically shifted from a charity based/ medical model approach toward a human rights/empowerment framework with hundreds of NGO implementing them nationwide (Alam, Bari, and Khan, 2005).

The advantages to CBR with human rights frameworks is how the immediate needs and concerns with food, shelter and employment are joined by the equally pressing long-term issues such as discrimination. Experts within this framework include more than doctors and other professionals, people labeled with disabilities in the specific contexts being served are invaluable leaders. Within the social model, a CBR's main tenets revolve around empowering people labeled with disabilities into every level of the decision process; they are, like others, uniquely informed by their experiences with navigating cultural barriers and advocating for equity.

In a review of past CBR practices, Turmusani, Vreede and Wirz, (2002) note that although the social model of CBR is dominant in Western societies, developing countries, "lack resources for welfare systems and they are not familiar with concepts of human rights and equality in the manner of the West" (p. 561) resulting in a greater preference toward the medical model of disability. Mitchell (1999) identifies four aspects of CBR for evaluating their effectiveness: service delivery system; technology transfer; community involvement; and organization and management. A case where a CBR in Bangladesh dealt with immediate and long term issues through medical care and community outreach is the Chakoria CBR begun by Social Assistance and Rehabilitation for the Physically Vulnerable (SARPV) in 1991. Though they began with the goals of providing relief from a cyclone, SARPV employees found, "that people with disabilities played no role anywhere in society, not even in [the] family in which they belong" (Haque, 2008, p. 5). SARPV moderated information sessions with various community stakeholders to highlight the plight of people labeled with disabilities. In a follow up, in 1992 SARPV worked with the Unitarian Universalist Service Committee to develop a self help group for people labeled with disabilities (Haque, 2008). While goals for some CBR involve providing western technology and service models have been met, neglecting the cultural context of what disability means in a particular society and how it plays out on a daily basis, may inadvertently reinforce, "perpetuating negative attitudes and practices towards disabled people" (p. 561).

Poverty reduction strategy papers and the law

In theory, poverty reduction strategy papers (PRSP), developed by the World Bank in 1999, have equitable participation by all stakeholders during formulation, implementation, monitoring, and evaluation (Coleridge, 2007). In reality, after disability issues were overlooked in the Interim PRSP of 2003, Action on Disability and Development (ADD) collaborated with a local NGO and conducted 23 consultation meetings country-wide with 1,475 participation including a Minister of State (Andrade, Kanto, Sivalingam, and Swimer, 2005). The result of the meetings included a set of recommendations to be added to the PRSP and a television and print campaign to heighten awareness about disability rights in the PRSP (Andrade, Kanto, Sivalingam, and Swimer, 2005). The Bangladesh Government changed their approach to the PRSP process by facilitating one national and six divisional consultations where people could voice their concerns. The National Forum of Organizations Working with the Disabled (NFOIWD) facilitated the attendance of people labeled with disabilities resulting with disability being incorporated as an independent issue (Alam, 2007). In the 2005 PRSP, disability is mentioned in regard to child rights issues and access to primary education. In a larger section titled, Disabled People, seven fields are signified for future action. These fields are: data collection; policy formulation and coordination; education access for 'disabled children'; the health sector; income-earning activities; access to public services; and inclusion in national and community level decision making process that impact the lives of people labeled with disabilities (Andrade, Kanto, Sivalingam, & Swimer, 2005). Besides laying forth a disability policy in PRSPs, a few anti-discrimination laws have passed in the last twenty years.

In 1995, a national policy for persons with disabilities was approved by the Cabinet for constitutional provisions covering the right of those labeled with disabilities. The policy was an adoption of the United Nations Standard Rule on the Equalization of Opportunities for Persons with Disabilities. This was followed by the Disability Welfare Act of 2001, that denotes national and district level responsibilities on disability issues. A long held concern about the Disability Welfare Act of 2001 was echoed at a 2007 roundtable in Bangladesh — it lacks the cultural capacity building to confront cultural discrimination (Staff correspondent, 2008). The 2001 Act set forth in motion a few governing bodies who were supposed to provide rehabilitative services without much mention of other concerns to people labeled with disabilities, such as discrimination. The National coordinating council works with district coordination councils on disability issues. Working with NGOs, the National Foundation for the Development of the Disabled People provides funding to NGO activities that serve people labeled with disabilities. Commenting on the integration of these services, Mojaheed (2004) concludes that they need greater extension and expansion through an increased role from people labeled with disabilities, their families and other community stakeholders (Mojaheed, 2004). As in other examples, the lack of perspective from a merely individualistic medical model of impairment instead of a social model where other factors, such the active and equitable participation of people labeled with disabilities in decisions processes, has lead to a short-sighted failure.

Alam and Choudhuri (2003) also question how the Disability Welfare Act of 2001 both lacks legal recourse against those individuals or companies that violate the legislation and creates unresolved conflicts with standing education and employment laws. They suggest a provision of conviction in the legislation and a program to raise anti-discrimination awareness through the mass media (Alam and Choudhuri, 2003). Finally, the Asia-Pacific Development Center on Disability in a 2003 country profile claims that the Government has failed to enact or amend laws and regulations or set safety standards for industry that protects their constituents.

Concluding Discussion

Bangladesh has undergone economic, political and infrastructural change resulting in growth, yet, the difference between rich and poor has only grown. The predicament for many labelled with a disability and their families is greater than their perceived disabilities. Attempts to assist those in poverty and labelled with a disability through micro-credit programs are often mired because lenders do not factor the greater cultural mechanisms of discrimination and, hence, they are not being constructively dealt with. The economic opportunity of an increasing non-farm labor force in Asian counties is a reality (Estudillo and Otsuka, 1999; Hayami and Kikuchi, 1999; Jayaraman and Lanjouw, 1999; Lanjouw and Stern, 1998; Quisumbing and others, 2004) but who gets those opportunities now is limited to those without disabilities and, in some cases, without family members with disabilities. In short, apart from the deterioration of relationships and social interaction, people labelled with disabilities in Bangladesh encounter programs that ignore their contexts or confront discriminatory beliefs. Systems set up to aid them are run by experts who do not live in the communities they serve and hold perspectives on disability where only the individual category of disability is present as opposed to the obvious impact of context and status. In terms of micro-credit programs — often negatively viewed because the money goes to short-term need and does not provide a boost out of poverty (Chowdhury & Wright, 2005; Hoque, 2004) and where the connection between useful vocational skills and actual market needs are misplaced (Alam, 2005) — the social model holistically views cultural processes so researchers can better conceptualize the relations to and political nature of discrimination.

There has been much praise for some micro-finance leaders in Bangladesh. Making an authentic and transparent effort to further include people labelled with disabilities would benefit their corporate image and their country. One alternative to past failed attempt to fully address disability rights issues in Bangladesh's PRSPs is to integrate disability into future editions in the same way as gender and by utilizing disability-specific outcome indicators (Danish Bilharzias Laboratory, 2004). As for the laws, DPOs and other like-minded and socially active organizations have lead to great change for the rights of people labelled with disabilities in the United Kingdom and the United States (Charlton, 1998). Yet similar goals must be advanced and augmented by NGOs and the government. Realizing who authentic and informed experts are and what they can provide will be a resounding move in a rights- based direction only if they are given a true opportunity.