by Robert Lalasz

(January 2005) As the death toll continues to rise above 150,000 from last month’s Indian Ocean tsunami, women who survived the disaster now face difficult and special challenges—such as getting access to maternal and reproductive health care, protecting themselves from sexual abuse in refugee settings, and perhaps taking on new roles as primary economic providers for their families.

“It’s not unlike a conflict setting,” says Sandra Krause, director of the reproductive health program at the Women’s Commission for Refugee Women and Children, a New York City-based nonprofit affiliate of the International Rescue Committee. “At every point in the relief and reconstruction effort, the particular needs of women have to be addressed.”

Providing Reproductive Health Care and Preventing HIV Transmission

Krause and others say that the response to the Indian Ocean tsunami reflects the international community’s growing awareness over the last decade of how natural disasters and armed conflict affect women and children. The need is great: The tsunami left women without access to vital health services in affected areas of Indonesia, Sri Lanka, India, and other countries, destroying many clinics and leaving midwives and health workers displaced and without supplies. The United Nations Population Fund estimates that 500,000 women and girls in Sri Lanka alone have been displaced.

UNFPA also says that at least 150,000 women in tsunami-affected regions are currently pregnant or may be facing complications of pregnancy, including trauma-induced miscarriages. And more than 50,000 women within affected communities will give birth in the next three months.

However, a set of international guidelines developed by a consortium of UN agencies, NGOs, and government representatives—the Minimum Initial Service Package, or MISP—seeks to ensure that reproductive and maternal health needs are met during refugee situations. These guidelines are designed to prevent excess maternal and neonatal morbidity and mortality, to reduce HIV transmission, to prevent and manage the consequences of sexual violence, and to plan for the provision of comprehensive reproductive health services as the situation permits.

“It’s a priority set of activities for all humanitarian emergencies, although it’s not as well known as it should be among some humanitarian agencies,” says Krause, who has worked in conflict-affected settings in Chad, Somalia, eastern Sudan, and Thailand, among other locations.

Krause says that UNFPA has moved quickly to distribute midwife supply kits as well as rudimentary delivery kits directly to women in the affected areas. The delivery kits include provisions for safe child delivery, including soap, plastic sheeting to lay on the ground, a clean razor blade for cutting the umbilical cord, a piece of string for tying it, and cloth to wrap the baby immediately after delivery.

UNFPA is also distributing clothing and personal hygiene kits to women in the affected regions—a crucial need in these traditional societies, according to Janet Momsen, a professor of economic geography at the University of California-Davis who has written extensively about gender and development in South Asia.

“Loss of privacy is also a major problem for women in terms of the cultural expectations in these patriarchal societies,” says Momsen. She adds that women doctors are crucial to the relief effort, because many women in South Asia will not go to male doctors.

The MISP also highlights steps to reduce HIV transmission during refugee situations, including respect for universal precautions against the virus such as condoms and the proper disposal of needles by injecting drug users.

According to Krause, this effort includes making condoms free and available to both refugees and relief personnel in a culturally sensitive way. “It doesn’t mean doing an HIV campaign or distributing them visibly, which could be offensive to some,” she says.

Removing the Threat of Sexual Violence

Humanitarian agency officials are also alarmed about the possibility of widespread sexual violence against women and girls displaced by the tsunami. Ten days after the disaster, UNFPA was already reporting incidences of sexual exploitation, rape, and even gang rape in some affected areas.

But protecting these women and girls involves more than added security in refugee centers. Even the way aid is distributed to refugees or the lighting and placement of latrines in camps can place women at risk of attack, according to Wendy Young, director of external relations for the Women’s Commission for Refugee Women and Children.

“When women become the passive recipients of assistance and aren’t involved in its distribution, you inadvertently put them in a vulnerable position,” says Young. “They have to approach and ask for assistance, which may be implemented by people who want to harm them.” Both Krause and Momsen add that women in refugee camps often are forced to exchange sex for survival needs because they don’t feel safe to go out and gather fuel, food, or clean water for themselves and their families.

The MISP recommends that women who have suffered from sexual violence and rape should have immediate access to medical care as well as emergency contraception to prevent pregnancies. In addition, the package advises that relief efforts include workers who can give proper clinical care to survivors of rape. Krause says that there have been efforts to address these needs in the wake of the tsunami, including the distribution by UNFPA of emergency rape treatment kits.

Young says early reports make her cautiously optimistic about these efforts as well as the protection of refugee women from sexual traffickers. “In the context of an extraordinarily difficult relief effort overall,” she says, “the international community seems to be aware that these goals are important.”

Women Often Assume New Roles as They Rebuild Their Lives

Without targeted long-term aid and programs, however, many women who survived the disaster will have difficulty transitioning from refugee centers back into the community, according to Momsen.

“The livelihoods of many of these women will have been linked to their husband’s fishing or farming activities, which are no longer taking place,” says Momsen. “Some of the women may have had small stores or kept a few domestic animals for milk and eggs. It appears that all such small enterprises have been destroyed [in the affected areas of Sri Lanka].”

Momsen urges that reconstruction efforts focus first on rebuilding schools and clinics—which provide services, jobs, and (in the case of schools) a sense of place and normalcy for children.

Many women survivors, however, will have to take on the burden of earning a living as well as caring for remaining family members. “We found in the Balkans that these women have to change their way in the world,” says Elaine Hanson, academic director for the University of Denver’s International Center for Disaster Psychology and an assistant psychology professor at the university. Hanson adds that such women will need occupational and financial training as well as support for their role change.

“Just to stabilize the situation is going to take a long, long time,” says Krause. “To rebuild will take even longer.”

Robert Lalasz is senior editor at PRB.