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The Second Fifty Years: Promoting Health and Preventing Disability
sensitive to the long-term needs of people with disabilities and that is likely to lead to a more unified understanding of these concepts among health professionals.
Even without many of the political pressures that accompany efforts to certify individuals for government benefits, the task of disability classification remains deeply complicated. There are major incompatibilities between the thinking that currently dominates American health care and the service needs of people with disabilities. The following sections give an account of these difficulties, discuss the current state of affairs in disability classification and its effects on disability research, and explain the committee's decision to advocate the World Health Organization's system.
DISABILITY AND THE DISEASE MODEL
The dominant framework for understanding the majority of health problems in the United States is that of the acute care community, that is, the disease model. Yet more and more health professionals are beginning to question the wisdom of using this approach to meet the needs of people with disabilities and those at risk for disability2,8,19—in particular, the elderly, the fastest growing group at high risk for disabilities.16,17 An acute care framework provides a poor view of disability for a number of reasons. Acute care perspectives are primarily restricted to somatic conditions, yet contemporary concepts of disability include phenomena that go well beyond this sphere. Disability may limit an individual's capacity to live independently or care for him- or herself; it may interfere with maintaining or initiating relationships, pursuing career goals, or enjoying leisure activities. Disability may also erect barriers to personal autonomy (e.g., the inaccessibility of public accommodations) and political empowerment (e.g., through prejudice or discrimination) in American culture.
The acute care perspective on health is also problematic for understanding and meeting the needs of people with disabilities and those who are at risk for disability. In the acute care framework, health is most often associated with cure, a linkage that is too limiting in the disability arena. (Some of the problems inherent in the health-equals-cure perspective are apparent when one considers that there is a cure for tuberculosis but no counterpart in treatments for missing or dysfunctional legs.) Health care that reduces its ultimate goal to that of the strictly curative is also likely to make the implicit assumption that health and the absence of disease are essentially synonymous. This assumption makes room for primary