Intended for healthcare professionals


People with intellectual disabilities

BMJ 2004; 329 doi: (Published 19 August 2004) Cite this as: BMJ 2004;329:414

Health policy and intellectual disability

EDITOR---This communication in response to the recent editorial by
Sally-Ann Cooper, Craig Melville and Jillian Morrison on people with
intellectual disability and health inequality (1).

More than 25 years have passed since the shift in care for people
with intellectual disability from institutional to community care (often
called de-institutionalization or normalization), but many gaps prevail in
many domains of the medical system and in the ideology of providing care


We have not yet succeeded to overcome that kind of shift from
institution to community care and we are facing the new transition
characterised by aging, increased life expectancy and accumulation of
degenerative diseases and chronic illness characterising the general
population (3).

This increase in life expectancy contribute to the increasing number
of people with intellectual disability and the aging of this population
(4,5). If the population does not receice health surveillence these people
with intellectual disability will have a significant functional decline,
increase the burden of disease and demands more expensive resources with
higher cost due to high technology services (6). If this trend is expected
and measures taken to accomodate health promotion, screening and focus
shifted to a healthy life style, we would expect to have less disability
and dependence among people with intellectual disability (7) .


Most of the burden of diseases in later life, much earlier in people
with disabilities than the general population could be caused in large
extent by chronic diseases and their consequences that causes functional
decline and decrease quality of life. Thus we need more screening, bigger
efforts to diagnose early, better compatile models for case management of
chronic diseases and prevention of complications and secondary diseases
caused by disability (8,9). It is known now that most of the disease
burden among people with intellectual disability is caused not by the
level of disability, but rather by the level of functional decline
accompanying it (10).


In order to have models of services addressing universal and unique
needs of this population, there is an imminent need for their inclusion,
not only in the community but also include them in trials and projects
addressing health promotion, screening, health education, use of
therapeutic and diagnostic measures. This should be done in order to avoid
adopting evidence from the population without intellectual disability to
this population, because there could be a danger as proved to be with
other parts of the society (11,12).

Policy makers are always worried about an increase in costs of
services, if there would be a shift to address needs and expectations of
this population with disability. This in spite of evidence that many of
the causes of morbidity and mortality leading to higher utilization of
services in this group are either curable or preventable and therefore an
investment in earlier age would show cost-benefit (13,14).

Socio-economic factors were found to be much more implicated in
health status and morbidity of people with intellectual disability than
the rest of the population, demanding interventions of other authorities
beside the medical community (15).


Supports of professional staff may be expensive (16), but does not
seem or was not proved to be better than informal support or support
offered by voluntary or other specific remedial communities, except for
the medical care in its narrow spectrum.

Finally, regarding the role of legislation to remove disparities in
health is not straightforward, but has to be coupled with a change of
attitudes in the public, professionals and policymakers and there has to
be a political clear agenda with the core of inclusion of people with
intellectual disability woven firmly into it.


Mohammed Morad, MD, is a family physician, the medical director of a
large area clinic in the city of Beer-Sheva, Israel. E-mail:

Ilana Halperin, medical student, Faculty of Medicine and Dentistry,
University of Western Ontario, Canada. E-mail:

Aliza Shupac, political science student, Faculty of Arts, Department
of Political Sciences, McGill University, Montreal, Quebec, Canada. E-

Joav Merrick, MD, DMSc is professor of child health and human
development, director of the National Institute of Child Health and Human
Development and the medical director of the Division for Mental
Retardation, Ministry of Social Affairs, Jerusalem, Israel.
E-mail: Website:


1. Cooper A-A, Melville C, Morrison J. People with intellectual
disabilities. Their health needs differ and need to be recognised and met.
BMJ 2004;329:414-5.

2. Aspray TJ, Francis RM, Tyrer SP, Quilliam SJ. Patients with
learning disability in the community. BMJ. 1999;318(7182):476-7.

3. Harwood RH, Sayer AA, Hirschfeld M. Current and future worldwide
prevalence of dependency, its relationship to total population, and
dependency ratios. Bull World Health Organ 2004;82(4):251-8.

4. Merrick J, Kandel I, Morad M. Health needs of adults with
intellectual disability relevant for the family physician.
ScientificWorldJournal 2003;3:937-45.

5. Patja K, Iivanainen M, Vesala H, Oksanen H, Ruoppila I. Life
expectancy of people with intellectual disability: a 35-year follow-up
study. J Intellect Disabil Res 2000;44( Pt 5):591-9.

6. Thyen U, Sperner J, Morfeld M, Meyer C, Ravens-Sieberer U. Unmet
health care needs and impact on families with children with disabilities
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7. Harwood RH, Sayer AA, Hirschfeld M. Current and future worldwide
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9. Merrick J, Davidson PW, Morad M, Janicki MP, Wezler O, Henderson
CM. Older adults with intellectual disability in residential care centers
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10. Carmeli E, Merrick J, Kessel S, Mashrawi Y, Carmeli V. Elderly
persons with intellectual disability: a study of clinical characteristics,
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13. Conroy JW. The small ICF/MR program: dimensions of quality and
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14. Emerson E, Robertson J, Gregory N, Hatton C, Kessissoglou S,
Hallam A, Knapp M, Jarbrink K, Walsh PN, Netten A. Quality and costs of
community-based residential supports, village communities, and residential
campuses in the United Kingdom. Am J Ment Retard 2000;105(2):81-102.

15. Fujiura GT. Continuum of intellectual disability: demographic
evidence for the "forgotten generation". Ment Retard 2003; 41(6):420-9.

16. Hallam A, Knapp M, Jarbrink K, Netten A, Emerson E, Robertson J,
Gregory N, Hatton C, Kessissoglou S, Durkan J. Costs of village community,
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Competing interests:
None declared

Competing interests: No competing interests

22 August 2004
Mohammed Morad
Medical Director
Ilana Halperin, Aliza Shupaz, and Joav Merrick
Clalit Health Services Shatal Clinic, Rehov Similanski 79, , IL-84223 Beer Sheva, Israel