The Pakistan earthquake and the health needs of women

Although natural disasters do not distinguish between genders, they do have a different impact on men and on women. The 8 October earthquake that rocked the northern areas of Pakistan and Azad Kashmir was no exception. The earthquake affected women physically, mentally and socially. Confronted with such a large tragedy, in which 87,000 people were killed and 3.5 million made homeless, the government and other agencies failed to specifically address the needs of women, who faced an increase in violence, had limited access to aid and had special unmet needs relating to pregnancy and nursing infants.

Marie Stopes Society (MSS) was established in Pakistan in 1990, and is an affiliate organisation of Marie Stopes International (MSI), a UK-based organisation with partners all around the world. Over the years, MSS has provided specialised services to more than 3 million people in Pakistan through its 50 centres in 20 cities. All MSS clinics provide a full range of reproductive health and family planning services. It was with this expertise that MSS responded to the needs of people affected by the earthquake. MSS focused its efforts in Hazara, Manshera, Shangla and Battal, providing obstetric and reproductive health care and general emergency medical aid. This article is based on observations by MSS concerning the provision of assistance to women in earthquake-affected areas.

The shelter response and women

Immediately after the earthquake, the first priority for the government and other actors was to provide shelter to the survivors. Most homeless people were moved to tented camps set up by the government and relief agencies. Although these camps provided much-needed shelter and basic food rations they did not offer psychosocial support. A survey carried out by a local NGO, Shirkat Gah, and the Agha Khan University (AKU) showed that most of the women in these camps were suffering from high stress levels due to living in close proximity to non-relative males.

Women who were widowed or were looking after injured family members faced significant obstacles in accessing relief goods. This is because society in Pakistan is organised to protect the family institution, and women play a critical role in upholding the honour and integrity of the family name. Thus, women are chaperoned outside the house so that their safety and reputation can be ensured. This restricts their mobility, and was one of the main reasons why women were not able to access emergency relief supplies. Camp management and security were critical issues, and incidences of sexual harassment added to the difficulties women faced.

Most of the camps were cramped and there was no private space for spouses, which resulted in tensions and conflict. Fights erupted over minor issues. For example, a 23-year-old mother of two was taken to a hospital after her husband assaulted her for not cooking food to his liking. Coping mechanisms for both males and females were non-existent, and domestic violence increased. Child abuse also rose as parents vented their frustrations on their children.

The needs of pregnant women

According to the UN Population Fund (UNFPA), immediately after the earthquake at least 40,000 women in the affected areas were pregnant, and needed adequate nutrition, medicine and antenatal care to deliver safely. Even in the best of circumstances, some 15% of these women would require emergency obstetric care. It is likely that the physical and psychological trauma caused by the earthquake pushed this figure higher still.

Most of the major hospitals and clinics in the earthquake area were completely destroyed. Many women were not allowed to see a male doctor and therefore were denied medical care. The tradition of observing purdah and being confined to the house is very strong, and women have less access to hospitals. Meanwhile, the government-sponsored Lady Health Worker (LHW) programme, a mechanism through which women usually receive medical support, was severely affected by the earthquake. The programme, formally known as the National Program of Family Planning and Primary Health Care, uses trained employees to provide doorstep service delivery, including basic preventive care and contraceptive supplies and referrals. Each health worker serves approximately 1,000 people in her community. Most lost their lives in the earthquake, making surviving pregnant women more vulnerable to miscarriages and still-births.

At the same time, it is an irony that many more facilities became available to women in remote mountainous region due to the earthquake. For example, a 28-year-old mother of six children was three months pregnant at the time of the earthquake, and desperate for an abortion, even though such a procedure is illegal. She lost her husband in the earthquake, becoming one of 63,000 widows, and was living in a makeshift tent with her children and extended family. She was finally able to have an abortion in a field clinic.

Many organisations also took the opportunity to give advice and counselling to women on family planning and safe sex. These women would have previously been very difficult to reach. Many women coming to camp clinics asked for contraceptives because they could not look after more children. With many men either dead or away from their families in search of aid and assistance, women had to care for children and elders largely on their own, and with few resources.

Hygiene and sanitation needs

In the initial call for emergency relief, women’s sanitary needs were ignored, and few agencies or NGOs sent sanitary supplies. There were also reports of men who were distributing relief aid taking out sanitary napkins and throwing them away because they regarded them as useless, or were uncomfortable with them. Some agencies bypassed this problem by handing out sanitary pads in health kits provided to children, who were told to give the pads to their mothers.

A lack of information and knowledge compounded the difficulties women faced. In Shangla, Kohistan District, women came to MSS staff with severe diarrhoea and skin rashes. During examination, staff found that they had all recently used the same toothpaste given to them by a relief agency. The women were asked to bring the toothpaste to the camp; it was found to be hair-removing cream.

Another particular problem that women faced in the camps was a lack of appropriate sanitation facilities. In the absence of toilets, men were able to use the fields at any time, but women only felt comfortable venturing out very early in the morning or at night. In one camp, in Balakot, two cousins were attacked while walking towards the latrine – they shouted for help and were rescued. Too embarrassed or fearful of their security to walk openly to latrines in the camps, many women relieved themselves in their tents despite the health hazards. The incidence of urinary tract infections was high. Women also no longer had the privacy to wash and dry the strips of cotton they use during menstruation.

Conclusion

The provision of gender-sensitive and women-focused assistance should become a priority in relief activities, so that women who have been through terrible trauma can live their lives with dignity. Efforts to ensure women’s equal participation with men in shaping the response should be mainstreamed in all aspects of the emergency and reconstruction phase. In the light of their experiences in Pakistan, agencies need to ensure that, in the future, they more adequately and appropriately address women’s needs.

Under the umbrella of the Joint Action Committee (JAC), a loose network of over 100 local NGOs, MSS and other local agencies developed the following checklist to ensure better provision of relief to women in earthquake-affected areas.

General and cross-cutting issues

1. How have men and women, girls and boys been affected by the disaster and displacement? Have women and men been affected differently by specific events, such as the destruction of schools, roads, sanitation facilities, markets and homes?
2. What are the different coping mechanisms used by men, women, girls and boys? What resources/support are they using to survive? Are these in jeopardy or over-stretched?
3. Do women have equal access to resources? What would help increase their access?
4. What specific power structures can be identified within communities? What are the specific threats or risks facing women and girls in the current environment?
5. What are the prevailing attitudes, religious and cultural norms and practices that affect women’s ability to contribute to and benefit from assistance?
6. Are women and women’s organisations involved in decision-making? What barriers prevent women and girls from meaningful participation and involvement in decision-making? Is a participatory approach being used?
7. What programmes are in place to prevent and respond to violence, abuse and exploitation against women and girls, including trafficking?
8. Is data being collected and analysed by sex and age? What is the age and sex breakdown of those who died?

Health and nutrition

1. How is the health sector meeting the different health needs of women and men? Is access to services equal for men and women?
2. Are there women health providers (doctors, ob-gyns, midwives)? Do women have access to female health care providers?
3. Are reproductive health services available? Is the Minimum Initial Service Package (MISP) being implemented?
4. Are health and psychosocial services available for survivors of sexual violence?
5. What programmes are available to address the psychosocial/mental health needs of the community, particularly for women and girls?

Erum Burki is Advocacy Manager for Marie Stopes Society in Pakistan. Her email address is: erumburki@hotmail.com .