By Marlies Hesselman, University of Groningen Faculty of Law, PhD Candidate, m.m.e.hesselman@rug.nl

On  16 October 2017, GHLG member Marlies Hesselman participated in an event on  new CEDAW General Recommendation 36 on Gender and Disaster Risk Reduction in a Changing Climate . This two-part post is based on Hesselman’s commentary in response to the presentation of the Draft General Recommendation by CEDAW Committee member Hilary Gbedemah.  Part I  of this entry discussed the intimate links between gender, health, climate and disaster risk reduction and included examples of practical challenges for women.

Health Care in Draft CEDAW General Recommendation 36: Improving Protection for Women

The CEDAW’s Draft General Recommendation on Gender-Dimensions of Disaster Risk Reduction in a Changing Climate broadly acknowledges the health challenges for women in disaster settings in an elaborate paragraph, as a first ‘special area of concern’. The General Recommendation reaffirms for example that ‘health services and systems, including sexual and reproductive health services, should be available, accessible, acceptable and of good quality even in context of disaster’. In protecting the right to health, CEDAW States parties should put in place ‘detailed policies and budget allocations’, including for mental and psychological health, hygiene and sanitation, provision of pre- and post-natal care, emergency obstetric care and breastfeeding. Women should be involved in participation in decision-making regarding health and DRR, including the design and management of integrated health services for women in the context of disasters.

Other specific issues that are singled out by the CEDAW-committee, and that clearly resonate with the challenges faced by women as described in the previous post, are: menstrual hygiene management, access to the underlying determinants of health, oncological treatment and cancer screening (again, in disaster settings, women may miss essential planned hospital appointments), mental health and counselling, prevention and treatment of sexually transmitted diseases, family planning in disaster preparedness and response plans, emergency contraception, safe abortion, availability of qualified midwives, and the incorporation of mandatory, comprehensive courses on women’s health and human rights in training curricula for health workers, including the emergency services.

Finally, the General Recommendation submits that ‘health care providers should be made aware of links between ‘increased disaster risk, climate change and growing potential for public health emergencies as a result of shifting disease patterns’. Moreover, all health services operating in disasters should act to promote the human rights of women, including autonomy, privacy, confidentiality, informed consent, non-discrimination and choice’, while States are expected to monitor the provision of health services by public, non-governmental and private organizations. Especially this latter comment is very interesting, as it acknowledges the role and responsibilities of non-state actors in disaster management as well. We will return to this issue below.

It is valuable to note that internationally, the seminal document on Disaster Risk Reduction (DRR) activity is the 2015-2030 Sendai Framework on Disaster Risk Reduction (SFDRR). Health is addressed in various parts of this SFDRR, and thus, it may provide states and human rights supervisory bodies with further useful guidance about what it takes to protect the right to health through DRR. According to the SFDRR, DRR action on health (care) specifically includes: (i) improving DRR investment in safe hospitals and health facilities, (ii) ensuring access to basic health care services for all, (iii) improving ecosystem and environmental health and (iv) enhancing of preparedness for better response, inter alia through (a) considering safe hospitals as essential infrastructures for disaster management, (b) ensuring the stockpiling of necessary health supplies, (c) training rescue and health workers, (d) collecting health data on mortality and morbidity and (e) ensuring that mental health services are in place.  The CEDAW-committee also stresses the collection of disaggregated data especially.

As we saw in Part 1 of this commentary, these issues are certainly relevant to women in times of disaster, in terms of physical and mental health impacts, risks of related gender-based violence, but also the availability of sufficiently skilled personnel to deal with rape, pregnancy and maternal health issues during emergency situations. Another essential matter is the stockpiling of a range of essential health supplies for women. While a gender-dimension and a climate-dimension are part of the SFDRR, the document is not specifically tailored to these aspects.

In terms of factoring in climate change, the CEDAW GR36 could arguably also go a bit further in the paragraphs on health specifically. The impact of climate change on DRR and health are only marginally listed in para 53(g). Here, Intergovernmental Panel on Climate Change’s (IPCC)  work on health, climate and disasters may provide further useful insights to assist the human rights implications.

Crucially, the IPPC submits in respect of health care systems, that climate change adaptation can take the shape of incremental, transitional or transformational health care system reform (see also WHO’s Guidance to protect health from climate change through health adaptation planning and our GHLG study on the Right to Health and Climate Change. By way of explanation: incremental changes typically imply investing in better health outcomes generally, e.g. by simply improving access, availability and quality of health care and DRR activity, yet, without necessarily accounting for the possibly deeply disrupting additional impacts of climate change. CEDAW GR36 seems to call for these more general, incremental improvements in draft para. 53(b).

Transitional adaptation, however, would imply a clear shifting of attitudes and perceptions of climate risks, leading to initiatives such as vulnerability mapping and improved surveillance systems that integrate and respond to expected health impacts of (future) disasters and climate effects. It is certainly of interest that DRR activity (see the SFDRR) typically would require a practice of vulnerability mapping for future disaster events, i.e. surveying of risks and collection of health data, as well as putting in place early warning mechanisms and stock piling. Yet, a dedicated climate change perspective would arguably also require looking even further ahead, including assessments of how climate change may affect/change disaster patterns and thereby exacerbate/change health risks – and thus implying additional health care system needs. Arguably, CEDAW GR36 only very tentatively refers to this concept in para 53(g).

The importance of critically assessing future climate risks and DRR in health care systems is very usefully illustrated by evidence from recent heat waves in Europe(and here) or in Asia where health care systems were overwhelmed by patients and heat-related illnesses. The European heat wave of 2003 cost the lives of 70,000 persons, partly as a result of hospitals being poorly equipped. Key complaints included a lack of air-conditioning units or sufficient space in hospitals, and a tremendous strain on medical staff. It should be considered a great concern, already presently, that heat wave-related deaths are expected to increase 50-fold by next century in Europe. In terms of a gender-dimension: there is evidence that heat stress affects (pregnant) women differently or worse (cf, male risks in China however).

Transformational adaptation, finally, signifies a complete reassessment/restructuring of health care systems through the lens of climate change, especially in recognition that certain countries or regions will be deeply affected, perhaps in ways previously not imagined. This is certainly relevant for countries with large rural or urban populations at risk of major, disruptive droughts, (flash) flooding and hurricanes, which could require, for example, preparing for major humanitarian assistance activity. From a gender-perspective, adequate health care response requires an understanding of the social, economic and political lives of the women living in these affected regions (i.e. disaggregated data), their immediate and longer-term health risks and needs, and what is need to ensure access to essential health services before or after disasters. In all these situations –and in line with the right to health – access to health information will be crucial.

Unfortunately, the IPPC notes that transformational adaptation is (so far) not widely practiced, and also (https://iopscience.iop.org/article/10.1088/1748-9326/6/4/044009/meta) earlier studies suggest limited (awareness of) climate change adaptation in health care systems, even in recent times – let alone awareness of the needs for specific people, including women.

CEDAW GR 36 on the role of non-state actors in DRR

A final comment is in order on the role of Non-State Actors in the management of disasters, especially those of a severely disruptive, sudden-onset nature.  CEDAW’s GR 36 beautifully highlights the essential role of non-state actors in disaster governance in paras. 42-45; yet, it focuses mostly on companies, for example as managers of critical infrastructure. [NB. The role of private actors in disaster management has been recently analysed (here and here) and is the topic of a separate (forthcoming) blog post].

The role of private health care providers is specifically noted in paragraph 53(3). In this context, it is essential to note that also a gamut of civil society organizations is often deeply involved in disaster management. They may be first responders or ‘jump’ in governance gaps left by government – e.g. when States are not acting or are were inadequately prepared. A good example are the many NGOs providing access to free abortion services or other health services in the wake of Hurricane Harvey in the United States. It is important to acknowledge that NGOs should also act according to human rights standards, or, as recently stated by the Human Rights Council: should ‘strive to “do no harm” or minimize the harm they may be inadvertently doing simply by being present and providing assistance’. The CEDAW’s General Recommendation can provide useful guidance to States and non-state actors alike.

Conclusion

The CEDAW’s Draft General Recommendation proves a very useful, timely and comprehensive guidance document on Human Rights, Gender and DRR in a Changing Climate. It includes a clear focus on health as a ‘specific area of concern’. It is hoped that the GR’s implementation will take further shape in harmony with (the implementation of other) essential international DRR and climate change instruments, as key international documents can certainly mutually inspire each other to ensure the greatest protection. It will be as interesting to see the final text of the CEDAW’s General Recommendation in February next year, as it will be to follow the further entrenchment of health and (women’s) human rights in the UNFCCC’s future Conferences of Parties.