Integrating bioethics-driven rehabilitation to address non-communicable diseases and disabilities in Bangladesh and other low- and middle-income countries

Authors

DOI:

Keywords

bioethics, rehabilitation medicine, noncommunicable diseases, disability inclusion, LMICs

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Correspondence

Taslim Uddin
Email: taslimpmr@bsmmu.edu.bd

Publication history

Received: 17 Oct 2025
Accepted: 9 Dec 2025
Published online: 14 Dec 2025

Handling editor

Reviewers

Funding

None

Ethical approval

Not applicable 

Trial registration number

Not applicable

Copyright

© The Author(s) 2025; all rights reserved. 
Published by Bangladesh Medical University (former Bangabandhu Sheikh Mujib Medical University).
Key messages
Noncommunicable diseases are rapidly increasing in low and middle income countries, deepening disability and inequality. Integrating rehabilitation into NCD care is both an ethical and practical imperative. Guided by justice, solidarity, dignity, and capability, bioethics provides a framework for inclusive health systems. Physiatrists and rehabilitation teams play a vital role in promoting equitable care in Bangladesh and similar contexts.
Low- and middle-income countries (LMICs) are undergoing an epidemiological transition with noncommunicable diseases (NCDs) such as stroke, diabetes, and cardiovascular diseases rising sharply [1]. These conditions often lead to long-term disability, yet rehabilitation services remain peripheral in most health strategies [2]. Globally, 16% of people live with disabilities, but their needs are consistently marginalised. Rehabilitation, particularly under the leadership of physiatrists, offers a means to uphold justice and dignity in health systems [3]. This article argues for a bioethics-driven framework to guide disability-inclusive NCD management, with Bangladesh providing a case example [4].
 
Traditional biomedical ethics emphasises autonomy and beneficence, but LMICs require broader principles: distributive justice, solidarity, and the capability approach. Exclusionary practices—such as inaccessible facilities, discriminatory consent processes, and catastrophic out-of-pocket expenses—compound inequities. Stroke survivors, individuals with spinal cord injury, and those with diabetic complications often face functional impairment without adequate rehabilitation or assistive technologies [5]. Neglecting rehabilitation violates justice and undermines human dignity.
 
Rehabilitation operationalises ethical principles by restoring function, independence, and participation. Physiatrists lead multidisciplinary teams comprising physiotherapists, occupational therapists, speech therapists, psychologists, and social workers, ensuring comprehensive care. In LMICs, where systems are fragmented and resources are scarce, this leadership is essential.

Categories

Number (%)

Sex

 

   Male

36 (60.0)

   Female

24 (40.0)

Age in yearsa

8.8 (4.2)

   Education

 

   Pre-school

20 (33.3)

   Elementary school

24 (40.0)

   Junior high school

16 (26.7)

Cancer diagnoses

 

   Acute lymphoblastic leukemia

33 (55)

   Retinoblastoma

5 (8.3)

   Acute myeloid leukemia

4 (6.7)

   Non-Hodgkins lymphoma

4 (6.7)

   Osteosarcoma

3 (5)

   Hepatoblastoma

2 (3.3)

   Lymphoma

2 (3.3)

   Neuroblastoma

2 (3.3)

   Medulloblastoma

1 (1.7)

   Neurofibroma

1 (1.7)

   Ovarian tumour

1 (1.7)

   Pancreatic cancer

1 (1.7)

   Rhabdomyosarcoma

1 (1.7)

aMean (standard deviation)

Categories

Number (%)

Sex

 

   Male

36 (60.0)

   Female

24 (40.0)

Age in yearsa

8.8 (4.2)

Education

 

   Pre-school

20 (33.3)

   Elementary school

24 (40.0)

   Junior high school

16 (26.7)

Cancer diagnoses

 

Acute lymphoblastic leukemia

33 (55)

Retinoblastoma

5 (8.3)

Acute myeloid leukemia

4 (6.7)

Non-Hodgkins lymphoma

4 (6.7)

Osteosarcoma

3 (5)

Hepatoblastoma

2 (3.3)

Lymphoma

2 (3.3)

Neuroblastoma

2 (3.3)

Medulloblastoma

1 (1.7)

Neurofibroma

1 (1.7)

Ovarian tumour

1 (1.7)

Pancreatic cancer

1 (1.7)

Rhabdomyosarcoma

1 (1.7)

aMean (standard deviation)

Category

Key Factors

Weight

Strengths

Strong management support, skilled workforce, compliance with legal regulations

0.338

Weaknesses

Logistical complexity, inadequate segregation, financial constraints

0.13

Opportunities

Industry collaboration, environmental policies, new technology

0.094

Threats

Limited space, lack of coordination, high investment risk

0.329

Pain level

Number (%)

P

Pre

Post 1

Post 2

Mean (SD)a pain score

4.7 (1.9)

2.7 (1.6)

0.8 (1.1)

<0.001

Pain categories

    

   No pain (0)

-

1 (1.7)

31 (51.7)

<0.001

   Mild pain (1-3)

15 (25.0)

43 (70.0)

27 (45.0)

 

   Moderete pain (4-6)

37 (61.7)

15 (25.0)

2 (3.3)

 

   Severe pain (7-10)

8 (13.3)

2 (3.3)

-

 

aPain scores according to the visual analogue scale ranging from 0 to 10; SD indicates standard deviation

Aspect

Conventional dichotomous model

Emerging continuum model

Disease Classification

Dementia with lewy bodies (DLB): Cognitive decline manifests prior to or within 12 months of motor symptom onset.

Disease is conceptualised as a spectrum with overlapping onset of cognitive, motor, psychiatric, and sleep disturbances. No distinct temporal order governs the presentation of symptoms.

Parkinson’s disease dementia (PDD): Dementia emerges after at least one year of established Parkinsonism.

Neuropathology

Predominantly characterised by α-synuclein deposits. DLB often demonstrates more prominent cortical involvement, while PDD predominantly affects subcortical structures.

Extensive cortical and subcortical involvement of α-synuclein pathology in both DLB and PDD. Coexistent Alzheimer-type pathologies (β-amyloid plaques, tau tangles) observed across both entities, suggesting shared neurodegenerative processes.

Clinical Features

Cognitive impairment follows motor symptom onset in PDD, whereas DLB exhibits early cognitive symptoms. Both conditions feature Parkinsonism, visual hallucinations, fluctuating cognition, and REM sleep behaviour disorder (RBD).

A broader clinical continuum of cognitive, motor, psychiatric, and sleep disturbances with no rigid sequence, indicating that cognitive and motor symptoms may emerge simultaneously or in varying order. Common pathophysiological markers overlap between both forms of LBD.

Diagnostic Thresholds

Clear temporal distinction based on the onset of dementia relative to motor features, specifically the one-year cutoff rule for PDD.

Diagnostic boundaries are fluid, guided by clinical, pathological, and molecular markers rather than an arbitrary time frame. Both phenotypes represent variations within a spectrum.

Therapeutic Implications

Cholinesterase inhibitors and dopaminergic therapies are commonly employed, but treatment regimens are often stratified based on the temporal progression of symptoms, without regard for underlying pathophysiology.

A unified therapeutic approach tailored to individual patient profiles using biomarkers. Both cholinesterase inhibitors and dopaminergic agents are employed but with careful consideration of the individual patient's symptomatology and the risk of treatment-related side effects.

Clinical Trial Design

Clinical trials often restrict inclusion based on rigid diagnostic criteria, such as the one-year temporal cutoff, potentially excluding individuals with early cognitive or psychiatric symptoms and misclassifying patients.

Clinical trials are designed to accommodate the full spectrum of disease, focusing on biomarker-based phenotyping rather than rigid temporal criteria, allowing for more inclusive patient selection and better representation of disease variability.

In Bangladesh, the expansion of community clinics and community-based rehabilitation provides a platform for incorporating disability-sensitive NCD care, with union-level health and family welfare centres delivering services close to home [1]. Yet major constraints persist weak infrastructure, limited training, and underfunded services. Recognising rehabilitation as a core element of universal health coverage is therefore an ethical imperative [2].
 
Despite international commitments such as the United Nations Convention on the Rights of Persons with Disabilities, implementation remains weak. Rehabilitation and non-pharmacological strategies are often excluded from NCD plans, and disability-disaggregated data are scarce [6]. Emerging tools such as digital health and artificial intelligence risk widening inequities unless inclusivity standards are mandated. Social determinants like poverty, stigma, and climate displacement—further entrench exclusion.
A bioethics-driven rehabilitation strategy in LMICs should include:
   a) Mainstreaming rehabilitation in NCD policies.
   b) Strengthening physical medicine and rehabilitation leadership and expanding multidisciplinary training.  
   c) Ensuring universal accessibility—physical, digital, and communicative.
   d)Establishing social protection schemes to reduce out-of-pocket costs.
   e) Enforcing ethical governance of AI and digital health.
   f) Creating accountability mechanisms led by organizations of persons with disabilities.
These measures promote justice, solidarity, and sustainability in health systems.
In conclusion, rehabilitation in LMICs must be reframed as an ethical necessity rather than an optional adjunct. Embedding rehabilitation within NCD pathways secures not only survival but also dignity, participation, and independence for persons with disabilities. For Bangladesh, integrating bio-ethics into rehabilitation policy and practice offers both a moral obligation and a pragmatic route toward inclusive, resilient health systems.
Acknowledgements
None
Author contributions
Conception and design: TU, SPL. Manuscript drafting and revising it critically: TU, SPL. Approval of the final version of the manuscript: TU, SPL. Guarantor of accuracy and integrity of the work: TU.
Conflict of interest
We do not have any conflict of interest.
Data availability statement
Not applicable
Supplementary file
None
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