Historically, disabilities have been a basic fact of human life. Most men and women who became unemployed due to disability were reliant on welfare until well into the 20th century. Their situation has improved continually since 1960 with the introduction of social security and in particular disability insurance (IV). Yet, social insurance tends to reduce disability to the incapacity to work; the social and cultural needs of the disabled are often overlooked. Modern equality and integration policy seeks to prevent this.
Whether or not someone is considered disabled depends on a variety of factors. These range from physical and mental limitations, to barriers in everyday life and at work, from societal prejudices to life opportunities and available resources. Furthermore, the disabled have a wide range of different needs. The term ‘disability’ ultimately carries different meanings depending on the historical period.
Disability Before Modern Social Insurance
In previous centuries, disabilities were a part of everyday life for many men and women. A lack of adequate medical care or deficient nutrition resulted in difficult births, diseases or accidents leading to permanent bodily damage. Childhood and old age were particularly precarious periods of life. Sick children had a slim chance of surviving their first years of life and the natural aging process set in earlier than it does today. For instance, until well into the 19th century, a majority of people aged over 30 would already suffer from visual and hearing impairments. Men and women with disabilities additionally faced unwanted attention and social rejection. In the 19th century, the treatment of people with deformities or of short stature fluctuated between fright and fascination, as shown by the exhibition of ‘dwarfs’ and ‘freaks’ at fairs during this period. These kinds of birth defects were considered vagaries of nature, demonstrating either the variety of life or God’s wrath, depending on the perspective.
Physical defects in particular were widely seen as severe impairments to the working ability. Those who were thus unable to earn a living and could not count on the support of their families slipped into poverty and could find food and shelter in monasteries or hospitals. The disabled were granted special permissions to beg in many places. The ill and deformed were considered ‘the deserving poor’ and had a claim to support. In contrast, poor people able to work were typically denied access to welfare benefits in the 19th century. However, financial support for the disabled remained modest and did not take into account individual needs until well into the 20th century.
The belief in the individual’s ability to learn promoted since the Enlightment helped foster fundamental change to perception of the disabled and the emergence of modern curative education. Initially, this educational optimism mainly benefited people with sensory and mental handicaps. After 1800, numerous institutions were set up in Switzerland for the blind, deaf-mute and mentally disabled. This period also saw the rise of modern psychiatry that sought to cure people with mental illness. The new institutions – many of which still exist today – were based on a combination of spatial separation and special support measures. For instance, blind children were taught braille, and deaf children learnt to speak or, in exceptional cases, sign language. Once general compulsory education became enshrined in the federal constitution in 1874, many cantons and municipalities created assistance funds and special schools for children with learning difficulties who previously would not have been able to attend school. In the 20th century, the field of curative and special education was further expanded to include children with behavioural problems and ‘difficult’ youths.
Scientific innovations, particularly in hygiene and surgery, accentuated the medical attention on (physical) abnormalities in the 19th century. Orthopaedics thus specialised in normalising deformed limbs using gymnastic exercises and surgical procedures. Operation techniques were developed for treating clubfeet or goitre. Yet, the momentum of medical progress remained somewhat diffuse for the chronically ill and disabled. The new clinics distinguished between curable and incurable defects to a greater degree than the old infirmaries. Patients suffering from incurable conditions were therefore excluded from improved medical care. If they were destitute and had no families, they often spent their lives in poorhouses. An increasing number of curative and welfare institutions were established after 1900, such as for men and women suffering from tuberculosis.
How the disabled were handled gave rise to new fears in the 20th century. These fears were driven for instance by discoveries and assumptions in the field of genetic research. The disabled were called ‘inferior’, while deformities and defects were interpreted as signs of social decline. After 1900, however, eugenic aspirations also took hold within psychiatry as well as curative education, which put forth that hereditary diseases should not be allowed to be passed onto children. Corresponding policies, such as marriage bans or sterilisation – driven both by eugenic and socio-political motives – predominantly affected people with (alleged) mental disabilities, the psychologically ill and, to a lesser extent the deaf and blind. Criticism of the forced sterilisation of 400,000 disabled men and women, and the murder of well over 100,000 such people in National Socialist Germany led to growing rejection of eugenic practices in Switzerland after 1945.
The post-war boom and the liberalisation of many areas of society brought about changes in the attitudes people held towards the disabled. The aim of providing individual support now came to the fore, while arguments related to costs became less important. The issue of protecting and accepting disabled life has been the subject of renewed public debate since the 1980s, albeit in radically modified circumstances. Medical progress was reflected in two major aspects: for one thing, an increasing number of succesful therapies for treating and curing disabilities caused by birth or accident were developed. For another, major advances in prenatal diagnostics have resulted in disabilities being increasingly diagnosed before birth. Women and couples affected therefore face the difficult decision whether or not to have an abortion. At the other end of the life cycle, the increase in life expectancy has led to higher incidence of senile dementia and to a growing number of elderly severely impaired in their day-to-day life and requiring intensive care.
The Perspective of Social Insurance: Disability as Invalidity
Modern social insurance not only assumed the risk of disability; it also ascribed a certain meaning to disability. The social insurance schemes following the lead of Bismarck’s insurance system primarily viewed the disabled in terms of inability to work. Invalidity (the relevant term used in insurance) thus referred to a limitation of one’s capacity to work. It could be temporary or permanent, complete or partial, depending on the case. The degree of invalidity constituted an importance metric of insurance and was determined according to the income difference between the time before and after the incapacity to work. Consequently, insurance cover was initially limited to loss of income and hence to the employed.
Military and accident insurance, introduced in 1902 and 1918 respectively were the first classes of insurance to disburse pensions to disabled policyholders. Medical rehabilitation measures to restore their capacity to work were also included. Over time, pension funds (first only in the public sector, then later in private firms) paid out invalidity pensions too. That said, insurance cover remained selective and patchy. The insurance and its benefits were only available to employed policyholders – or to those who served in the military in the case of military insurance. In addition, accident insurance provided cover for accidents at work and recognised occupational illnesses only. The number of policyholders likewise remained limited. Only half of the workforce was covered by the Swiss Institute for Accident Insurance (Suva) until the 1980s. The number of workers insured by private companies, however, rose over the course of the 20th century. The focus on loss of income meant that those who were not part of the active work force – women, children and the elderly – did not have access to insurance. In other words, a large portion of men and women with disabilities continued to be dependent on welfare. This particularly affected people with birth defects who had never been able to work.
Closing these gaps in provision formed the main objective of the disability insurance (IV) which was enacted in 1960 following a long history as well as growing pressure from disabled persons (including the Swiss Association for the disabled). The IV took up the insurance concept of invalidity: pensions were primarily calculated according to the length of previous employment and the amount of contributions paid. Similar to old age and survivors’ insurance (AHV), the IV was conceived as a state insurance scheme and included persons with birth defects who had never paid any contributions. They were granted a minimal pension and later became eligible, like AHV pension recipients, for supplementary benefits and allowances. In addition, disability insurance made no differentiation between disability types. Furthermore, and this was an innovation in 1960 Europe – the IV extended its cover to include mental disabilities. Initially, the IV granted full and partial pensions that were graded depending on the degree of invalidity. A full pension was disbursed for an invalidity degree of 66.66 percent and above, while half pensions were granted in case of an invalidity degree of 50 percent. In 1986, quarter pensions were added for people with a degree of invalidity between 40 and 50 percent. Besides pensions, the IV also includes measures for medical rehabilitation and re-integration into the workplace. In addition, it is used for funding assistive devices, such as walking and hearing aids, and provides subsidies to special schools and institutions. Since 2011, according to new financial compensation rules, these institutions have been financed entirely by the cantons.
Disability insurance has been committed to the principle of ‘re-integration before benefits’ since its inception. Pensions are only disbursed to those unable to accept reasonable work despite re-integration measures. As the majority of men and women with (minor) disabilities remain integrated in the workforce, the number of IV pensions has always stayed relatively low. According to estimates, 600,000 disabled of working age lived in Switzerland in 2011; disability insurance provided 238,000 pensions in the same year. According to the re-integration principle, the disabled who apply for IV benefits first have to participate in a medical or occupational measure. This may involve therapy, retraining or the job placement. Disability insurance has always obliged policyholders to get involved such programmes. Otherwise, benefits can be forfeited or denied.
The number of new pensions increased sharply at the end of the 1990s due to the slump in economic growth, the economisation of work processes and a broadening of medical definitions of disabling illnesses. At the same time, political parties put the issue of insurance fraud on the political agenda. The pressure to improve integration of the disabled, especially those with mental illnesses, into the labour market increased in the 1990s to levels unknown before. The fifth IV revision (2008) therefore led to new measures concerning early detection and intervention which dissolved the actuarial division between invalids and non-invalids. Furthermore, measures were taken to strengthen cooperation between disability insurance, unemployment insurance and welfare. However, these new developments proved double-edged for the beneficiaries, particularly as austerity measures (such as the revision of old age pensions) were still the subject of political discussion. Re-integration attempts were bolstered on the one hand, whereas on the other, greater pressure was exerted on people with health problems to pursue work on the labour market, which often failed to take their needs into consideration.
New Approaches: Equality and Integration
Being disabled often comes with being discriminated against. Indeed, this has been the case in social policy too. For a long time, disability insurance has been a matter reserved to administrative officials, lawyers, doctors and actuarial mathematicians and excluding those affected. However, in the aftermath of the 1968 social movements, a younger generation of politically active disabled people increasingly called into question the authorities’ and experts’ power to define disability. For instance, the magazine ‘Puls’ broached issues such as buildings and housing suitable for the disabled, sexuality or the behaviour of people with and without disabilities. These were concerns that had previously been largely ignored in political debates. Switzerland’s disability policies were also critically assessed in the UN International Year of Disabled Persons in 1981.
The new movement for the disabled – with various disabled groups being involved to varying degrees – was driven by the demand for equality. Activists portrayed disability as a result of societal discrimination. Society therefore had a duty to adjust to the special needs of the disabled, and not vice versa. The issues of mobility, education and independent living were considered to be particularly critical. After the rejection of the fourth IV revision, which would have included the first cuts to benefits since the inception of the social welfare system, disability associations launched a popular initiative in 1998 with the aim of anchoring a comprehensive ban on discrimination in the federal constitution. Once Parliament had approved an indirect counterproposal, however, the electorate as well as a majority of cantons rejected the initiative five years later. The new Disability Equality Act (BehiG) therefore entered into force on 1st January 2004. Its core aspects dealt with access to public buildings, public transport and administrative services. In contrast to the term invalidity used by social insurance, the Disability Equality Act puts forth a broader understanding of disability. It views the degree of disability in the context of the ability to perform everyday tasks, maintain social contacts, move around and participate in education or training.
At the heart of the equality postulate is the promotion of integration and autonomy. The Disability Equality Act thus obliged cantons to promote integrative schooling at the expense of special schools. Previously, around five percent of pupils in Switzerland were taught in small, special classes. Now, children with disabilities were to be taught in regular classes wherever possible. Currently (at the time of writing in 2013), the implementation of the Act has only been partially completed and there exist significant differences between cantons. The independence of the disabled has likewise received greater emphasis in disability insurance. After it had been tested in several pilot projects, the sixth IV revision (Revision 6a) included assistance benefits. Those entitled to such payments who were living at home could now hire a third party for personal assistance services; costs would be borne by the disability insurance. This allowed the disabled to organise their own care to suit their individual needs. Depending on the case, this made accommodation in an institution unnecessary. The promotion of autonomy and personal responsibility are reflected in a reversal of financial flows. These no longer run from insurers to institutions, but are directly payed to the insured persons.
Literatur / Bibliographie / Bibliografia / References: Germann Urs (2010), Integration durch Arbeit. Behindertenpolitik und die Entwicklung des schweizerischen Sozialstaats 1900–1960, in: E. Bösl et al. (ed.), Disability History. Konstruktionen von Behinderung in der Geschichte, Bielefeld, 151–168; Kaba Mariama (2007), Des reproches d’inutilité au spectre de l’abus. Etude diachronique des conceptions du handicap du XIXe siècle à nos jours, in: Carnets de bord, 13, 68–77; Wolfisberg Carlo (2002), Heilpädagogik und Eugenik. Zur Geschichte der Heilpädagogik in der deutschsprachigen Schweiz, Zürich; Graf Otto Maria (ed.) (2011), PULS – DruckSACHE aus der Behindertenbewegung. Materialien für die Wiederaneignung einer Geschichte, Zürich.