Over the years, members of the Society for Disability Studies (SDS) and subscribers to DSQ have commented on and argued about the relationship between Disability Studies and the health-related and rehabilitation professions. Today, from my perch as Associate Dean of Disability Programs in a School of Health and Rehabilitation Sciences, my outlook is not much different from what it was years ago. Yes, a Disability Studies perspective is both compatible with and necessary to education in the health-related and rehabilitation professions. Yet, the strategies to implement this goal continue to be elusive. Few would argue, however, that the town (the disability community) and the gown (academic programs and professional organizations) must seek common ground—and that examples of partnerships exist. While others may focus on undergraduate education, this particular commentary targets graduate education.

In other venues, I have suggested that the emerging integrative model of disability can serve as a common value framework, a basis for change in curricula, professional infrastructure, consumer and professional attitudes and health policy and regulation. (Seelman, 2002, 2003). This model incorporates the ideals of consumer empowerment and participation, in part because consumers and professionals developed it together. The integrative model reflects the evolving maturity of the disability and professional communities. Disabled people recognize that, like all people, they, too, require health services and supports. Professionals are beginning to view people with disabilities more holistically. Intrinsic to the model is a health and rehabilitation framework of continuum of care from acute care to community-based services and supports. Consumer roles are not limited to, but include advocacy, and professional roles are not limited to treatment but also include advocacy. Consumer role options are broad—citizen, parent, student and worker, even health worker. The integrative model is operationalized in the World Health Organization's (2001) "International Classification of Functioning, Disability and Health" (ICF), the Institute of Medicine's Enabling America and the National Institute on Disability and Rehabilitation Research's Long Range Plan. These documents challenge the medical and the social models by providing a vision that incorporates health and rehabilitation into the continuum of human needs of a whole person living in society.

It is naïve to approach change without acknowledging the great power and resources that reside in the status quo and the incentives that support inertia. Any strategy to impart the disability perspective into the context of education of professionals must include a concerted effort to open, and become familiar with, the contents of the black box in which professional infrastructure has long been protected. Within the black box are the standard curricula of the professions and the processes, procedures and organizations that govern change.

However, change initiatives themselves can be launched from many organizational locations using a variety of strategies. Starting with the integrative model as a basis for agreement, the next step is to formulate and execute strategies in a systematic way that stimulate the "powers that be" in education, professional and consumer organizations, and public policy and regulation, to embrace and infuse this model into their curricula, Codes of Ethics, Standards of Practice, organizational infrastructure and initiatives in health policy and regulation.

A recent inquiry provides a snapshot of some of the challenges that face those of us working in universities as we strive for change in the professions. Not long ago, a national consumer organization contacted me to inquire about a pool of students might be interested in serving as paid interns in its Washington, D.C. office. When I queried various Department Chairs and clinical placement faculty, they responded as one indicating that only the undergraduate curriculum could accommodate such a request. Academic departments must show compliance with a myriad of stringent, outcome-based curricular requirements to receive the official stamp of approval from their respective professional bodies. Graduate students in the departments of Occupational Therapy (OT), Physical Therapy (PT), Speech Language Pathology (SLP), Audiology, Rehabilitation Science and Technology and Counseling are already very tightly and sequentially scheduled to meet academic and clinical practicum requirements of professional accrediting bodies such as the Commission on Rehabilitation Education (CORE) in the case of counseling. In addition, students are reluctant to prolong their time in graduate school by adding even a very valuable elective. They are burdened by increasingly hefty debt loads that are incentives to join the workforce as soon as possible. Health policy has set into motion a chilling configuration of cost- generated constraints on professional practice and consumer care. Efforts to privatize Medicare and block grant Medicaid aid and abet the objectives of those who regard health care as a commodity, not a right.

The professional, clinical and policy incentive/disincentive mix is skewed to favor the status quo. It creates barriers to realizing the benefits of teaching and learning about the experience of people with disabilities. How is our own School addressing these challenges? With the caveat that we can do much more, we have begun. Our Occupational Therapy Department has adopted the ICF as the framework for OT education. And, thanks in part to a Dean who "gets it", our School hires people with disabilities for faculty and staff positions, recruits students with disabilities and consciously inspires a culture that supports accessibility and inclusive attitudes. Both the Director and the intake coordinator for our community-based Center for Assistive Technology are people with disabilities, and professionals! The School has developed a number of other opportunities for students and faculty to learn about the disability perspective. These include a certificate program in Disability Studies and elective options, a course on third-party payment to hone professional advocacy skills for assistive technology reimbursement, a nascent Personal Assistance training project and strong ties to the Disability Community through faculty and student associations and service.

The School of Medicine has recently accepted its first student with quadriplegia. The University of Pittsburgh has established the Thornburgh Family Lecture in Disability Policy and Law in the School of Law and the School of Health and Rehabilitation Sciences.

However, initiatives for change cannot be limited to the individual academic University program or clinical setting. The organizational framework for the education of health-related and rehabilitation professionals--the contents of the black box-- suggests potential cases for study and entry points for infusion of a disability perspective into curricula, Codes of Ethics, Standards of Practice, organizational infrastructures and policy and regulatory initiatives. As a case example, why and by what process did the Code of Ethics for Rehabilitation Counseling incorporate a consumer empowerment guideline while so many other professional codes of ethics are silent on empowerment? Points of entry for change agents include: professional and consumer national and state membership groups, certification organizations and state licensing boards.

But, what organizations and individuals will take the lead within the community of those who recognize the need for the infusion of the disability perspective within the professions? Disability Caucuses within professional organizations may be promising organizational leaders. Members of the Disability Caucus within the American Public Health Association (APHA) have long been active in support of a disability perspective and adoption of the ICF. Caucus members have the public health professional credentials which lend legitimacy to the role of change agent. Recent annual national conferences of the Rehabilitation Engineering Society of North America (RESNA) have highlighted disability and advocacy issues in their clinical and policy sessions. These professionals and consumers are potential ambassadors of change in their respective consumer and professional organizations.

Turning for a moment to mainstream disability organizations in Washington, D.C., the American Association for People with Disabilities (AAPD), the largest disability consumer organization in the United States, has indeed worked in partnership with health-related and rehabilitation professional organizations on health issues, such as reimbursement, in order to change and protect health policy and regulation-related benefits. AAPD, the American Occupational Therapy Association, RESNA and others are currently working on the case of Operation Wheeler Dealer. The Center for Medicare and Medicaid Services (CMS, formerly Health Care Financing Administration or HCFA) had cracked down on access to power wheelchairs because of cases of fraud. The crackdown has been dubbed "Operation Wheeler Dealer." Operation Wheeler Dealer stimulated a mighty stream of responses from consumers, clinicians and industry each of which formed a coalition. The Independence Through Enhancement of Medicare and Medicaid (ITEM) Coalition in particular (http://www.itemcoalition.org/) brings clinicians and consumers into close partnership.

How can those who support infusion of a disability perspective into the health and rehabilitation professions capture, emulate and transfer these collaborative policy efforts to bring change in academic programs and professional and consumer organizations? Obviously, training modules crafted to provide continuing education units at professional meetings provide incentives to learn about the disability perspective and shared positions on key issues. Clinicians--often university-based with professional credentials and memberships in professional organizations—provide the academic expertise and an advocacy experience in the Item Coalition. They are well aware of the tension between their codes of ethics and the limitations imposed by managed care and the economic interests of profit within health care. Many clinicians in the Item Coalition are also well aware of the tension between Health Policy and Disability Policy. On the one hand, health policy may confine people to their homes and to nursing homes in order to receive benefits. On the other, disability policy identifies technology and personal assistant services as a means of realizing full participation in the community. The Disability Studies community cannot afford to boycott those professionals who share a common interest in change. Together they can make a difference in bringing their common position to professional and disability associations, building bridges that will support strategies to broaden curricula to reflect the interests of people with disabilities, fashion more participatory decision-making infrastructure and generate equitable health policy.

If the work of these coalitions can be transferred into professional deliberations on curriculum, infrastructure and policy, then opportunities for change in professional education become more promising. If the work of these coalitions can wend its way into consumer organizations and media, then consumers may be more supportive. They may more fully recognize that although the medical model is unacceptable, an integrative model provides a basis for necessary health and rehabilitation services and supports within a value framework that recognizes the full humanity of all people.

Please feel free to respond to this commentary directly to me at kds31@pitt.edu

Acknowledgments: I want to express my thanks to those who critically reviewed this commentary, especially Cliff Brubaker, Dean and Ellen Cohn, Assistant Dean, School of Health and Rehabilitation Sciences, University of Pittsburgh.

References

Institute of Medicine (1997). Enabling America: Assessing the Role of Rehabilitation Science and Engineering. Washington, D.C.: National Academy Press

Seelman, K.D. (2002). Disability Studies and the Academic Disciplines: Chasms and Bridges. Invest in Abilities Lectureship. University of Michigan at Lansing.

Seelman, K.D. (2003). Trends in Rehabilitation and Disability: Transition from a Medical Model to an Integrative Model. National Rehabilitation Conference Keynote. National Center for Persons with Disabilities. Tokorozawa, Japan.

World Health Organization, Geneva (2001). International Classification of Functioning, Disability and Health.