A guest blog by Laura Dean, Department of International Public Health, Liverpool School of Tropical Medicine
“If a woman with hearing impairment is raped by soldier, it is difficult enough as it is but she is also unable to communicate. How many of the structures that help tackle violence against women and girls are trained as to how to work with women with disabilities?”
Agatha, a women with physical disability, from What violence means to us: women with disabilities speak. Nigeria Stability and Reconciliation Programme. Inclusive Friends.
I was lucky to attend the launch of the Building Back Better initiative on gender in post-conflict health systems. Through case studies from Mozambique, Northern Uganda, Sierra Leone and Timor-Leste we explored how international efforts to rebuild health systems in post conflict or post crisis countries address or neglect gender equity. In many cases it was clear that a focus on gender often equated to a focus on sexual and reproductive health services. This presented some missed opportunities to build linkages across these vital programmes and the health sector as a whole.
Sexual and reproductive rights and disability
As a disability activist with a passion for sexual and reproductive rights, it was refreshing to be able to explore these issues in the context of how disabled sexualities linked to gendered vulnerabilities. In the 2011 World Report on Disability (WHO) stated that people living with disabilities, particularly women, have a high unmet need for sexual and reproductive health services. Sexual and reproductive rights for disabled people, particularly women, are often neglected even in peaceful settings, due to common perceptions of ‘asexuality’ or a lack of sexual desire or agency of disabled individuals. This often results in a lack of services and an invisibility of disabled people in sexual and reproductive health policy and programming.
During conflict disabled women experience high rates of sexual violence, exacerbating what is already a high unmet need for health services. In addition, conflict and crisis often increase prevalence of disability, resulting in higher numbers of people who are likely to need health services that are inclusive, adaptable, and recognise the different needs of people with differing impairments. Adaptability is critical when we think about the complex and varying needs of disabled people and links closely to the context in which services or individuals are located.
Diversity in disability
‘Disabled’ as a unifying concept represents vast layers of difference. Disability can relate to many different challenges people face, from those that are more physical to those that link to mental health. In addition, ‘being disabled’ is often not a fixed state, it is fluid with all individuals being situated on a continuum from able to disabled, it is the context within which the individual is placed which makes them more or less able. We know that in post-conflict and post-crisis settings disability and mental health are highly gendered vulnerabilities, as emphasised within the World Health Organisation’s 2013-2020 Mental Health Action Plan which presents gender as a key social determinant. When considering ‘building back better’ it is critical that we take into account the range of ‘disabling’ factors and the determinants that make them more or less disabling. Within this blog, I reflect on some of the opportunities presented to build back better post conflict and post crisis and the openings and challenges for the realisation of sexual and reproductive rights for disabled individuals that they present.
Building back better
There are a number of ways that we can improve post-conflict sexual and reproductive health services for disabled people:
- Strengthening health information systems: There is a need for data that is disaggregated by social stratifications such as gender and disability to build more responsive services and systems that reach all sections of society. This information is needed at all levels of the health system: national, regional, district and county. Perhaps more critical than collating this information however, is how the information is used. Innovative approaches to acting on this information could be shared through common platforms between activists and policy makers working on gender, disability, sexuality. The involvement of women, men, disabled people and those of all sexualities will be essential in ensuring innovative approaches to improving equity are successful.
- Inter-sectoral working: Unlike the humanitarian sector, development actors are particularly bad at working across issues and sectors. Organisations tend to work in silos related to their issue of choice. There are many vertical programmes operating within the health sector alone. Often disabled peoples organisations don’t think about issues of sexual and reproductive health and organisations working on sexual and reproductive health don’t think about disabled people and their needs. When we get the chance to re-build services or systems we have the opportunity to change this way of thinking to promote more unified co-ordinated responses. Creating cross-sectoral platforms for action around issues such as gender and disability are likely to enhance our ability to do this.
- Empowerment and creating spaces to demand the realisation of rights: In the Building Back Better event we heard comparative cases from Northern and Central Uganda. The case studies highlighted that in periods of conflict people sometimes become more aware of their rights when they are lost. We heard that in Zimbabwe, men and women disabled as a result of war, had led demands of inclusivity of disabled individuals within policy and programming for education and health with those disabled prior to conflict being much less involved. In some contexts, being disabled as a result of war may present an individual with less social stigma than those who were born with specific disability or acquired it through disease or illness. Through my work in Gujarat, India on disabled sexualities (unpublished) intersectional analysis showed that women who were more able to demand their sexual and reproductive rights were often those with better educational levels, economic status or those that had experienced neglect of their sexual and reproductive rights due to their disability. This seems somewhat unsurprising given the links we often see between education and empowerment, however little information currently exists on the social processes that allow the realisation of rights for disabled people and factors that empower disabled people to demand their rights. In periods of conflict, it could be argued that there is education through experience in relation to rights; when rights are lost or contexts change individuals perhaps become more aware that they existed. Lesson-learning from the work in Uganda suggests this would be an interesting area to explore. Understanding of such social processes is likely to contribute to the ‘nothing about us without us’ discourse that is critical within current disability movements.
- Community voices: Building Back Better participants felt that communities’ voices are often lacking in the process of reconstructing the health system post-conflict. We need to change our way of thinking as ‘expert’ researchers, technical assistants or government advisors, and begin to think of communities as agents of their own sustainable transformation. When given the opportunity communities are able to come up with their own solutions for positive change. As we strive toward universal health coverage and equitable access we need to ensure that we provide platforms to all, including those more marginalised because of their gender, sexuality, or disability. Defining priorities and addressing issues in this way allows for views of gendered identities to be shaped and embedded in local contexts as oppose to those suggested by technical experts. It is likely to generate new ways of thinking providing innovative solutions to historic problems.
Re-building health systems post-conflict or post-crisis provides an opportunity for change that can give prominence to issues that are often ignored such as gender and disability; how we manage such change is critical to ensuring more equitable societies. We have to consider each of the health system building blocks together, it is not enough to just provide services; we have to think about why people end up at services in the first place and how we can gather information about health outcomes and access. When we work together across issue areas and agendas we are more likely to succeed in establishing health systems that assist their citizens in the realisation of their rights.
Voices from the periphery: A narrative study of the experiences of sexuality of disabled women in Zimbabwe Christine Peta, Judith McKenzie & Harsha Kathard
Communal Violence in Gujarat, India: Impact of Sexual Violence and Responsibilities of the Health Care System Renu Khanna
Count me IN!: Research report on violence against disabled, lesbian, and sex-working women in Bangladesh, India, and Nepal Creating Resources for Empowerment in Action (CREA)
TARSHI (talking about reproductive and sexual health issues)