Forgotten Needs

Women and girls usually bear the burden of care for others during times of crisis, but their special health needs are often overlooked.

In the wake of any natural disaster, it is usually women and girls who assume the primary burden of caring for their families and obtaining food and other survival basics for entire households. Yet the magnitude and reach of the 26 December tsunami has in many cases led to unequal access to aid for women, the elderly, and other vulnerable populations. UNFPA staff deployed to some affected areas report that the majority of assistance is being distributed by men to men, with insufficient attention to targeting the most vulnerable or minimizing the possibility of exploitation.

To complicate matters further, women and girls have unique vulnerabilities – including pregnancy, the need for sanitary supplies and locally appropriate clothing, and a higher vulnerability to rape, trafficking, exploitation and domestic violence – that are often overlooked in relief and recovery planning.

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UNFPA Response

UNFPA priorities : to protect maternal health, prevent HIV, provide psychosocial support, and help ensure the security, hygiene and dignity of women and girls.

In the countries hardest hit by the tsunami, UNFPA has moved rapidly to protect maternal health and to help ensure the security, hygiene and dignity of women and girls. At the same time, the Fund has been working with local women's and youth organizations to reinforce their participation in relief, while planting the seed of recovery through reestablishment of reproductive health services and reinforcement of urgently needed psychosocial and counseling support. UNFPA is also working with partner agencies to advocate for and implement gender- and culturally-sensitive relief and recovery approaches in the ground. The Fund's regional response strategy includes:

Reducing maternal and infant mortality. Among the affected are at least 150,000 pregnant women. Like all expectant mothers, they require adequate nutrition and access to safe delivery support. Immediate UNFPA response has included supplying simple provisions for safe child delivery, as well as more sophisticated equipment and supplies for the reestablishment of comprehensive maternal services, including emergency obstetric care. The Fund has also been working with health authorities to improve access for displaced and remote populations through the establishment of maternal care in temporary shelters and the rehabilitation of damaged facilities.

Restoring reproductive health care, including HIV prevention. For couples that were using family planning before the disaster, sudden loss of access to these supplies and services creates an additional hardship and concern during an already difficult time. Restoration of family planning is often given very low priority in emergency response but neglecting it can have serious consequences, including unwanted pregnancies in unstable conditions, dangerous pregnancies in women who are too old or too young, and the transmission of HIV and other sexually transmitted infections. UNFPA has provided family planning supplies and assistance for the reestablishment of basic services in the communities hardest hit by the disaster. The Fund is also supporting HIV prevention by rapidly deploying condoms as well as medical supplies and equipment to ensure that universal precautions for blood screening and safe blood transfusion are observed in all medical settings.

Addressing sexual and gender-based violence, including trafficking and exploitation. Since immediately after the disaster struck, UNFPA has been working with national and local governments and community-based organizations to minimize and treat cases of sexual violence by supporting safe shelters for women, monitoring the distribution of relief supplies to prevent exploitation, and promoting personal security, including special facilities in temporary refuge shelters for unaccompanied women and children. UNFPA is also supporting treatment and counseling, and training to improve the sensitivity of health workers' response during a crisis.

Dignity and well-being, including hygiene. In the aftermath of the tsunami, people's needs extend beyond just food, water and other basics for survival. Soap, a washcloth, even a comb can do a lot to help someone who has lost his or her home to maintain some dignity. UNFPA has deployed hygiene kits to affected communities to meet these basic human needs, and is working with partners to make sure that sanitary napkins and locally appropriate clothing are part of the mix of emergency assistance.

Mental health and psycho-social support for community recovery. UNFPA is working with governments and local partners to provide psychosocial counseling and other support – to help men, women and young people deal with the devastating loss of loved ones, homes and livelihoods, and gather the strength they need to rebuild. Many mothers who have lost children are not only grieving but also experiencing survivor guilt, leaving them unable to care for remaining family members. Young people, already at a psychologically vulnerable time in their lives, have lost both family members and a sense of security. At the request of governments, UNFPA has helped to establish mental health and community groups to provide initial care for victims as quickly as possible, and developed programmes for longer-term support.

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Donor Support

Governments, foundations and private citizens have provided unprecedented levels of support to the Fund's tsunami relief and recovery efforts.

Donor response has been swift and generous. In addition to private donations from around the world, the Governments of Germany, Japan, the Netherlands, China, Norway and New Zealand have provided more than two-thirds of the funds requested by UNFPA to help meet urgent health, hygiene and protection needs for women and youth in Indonesia, Sri Lanka, and Maldives, the three countries hardest hit by the tsunami. Additional funds have been received from the Gates Foundation, the Hewlett Foundation and the United Nations Foundation. A number of companies and small organizations have also pledged support, including the tea producer China Mist, which donated one month's worth of profits.

The $28 million appeal by UNFPA was part of a UN-wide Flash Appeal launched 6 January in Jakarta, Indonesia, to help UNFPA and partners – including government ministries, local NGOs, and sister humanitarian agencies – meet extraordinary needs in the first six months.

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Maternal Health

UNFPA is helping to rebuild maternity clinics and reestablish health services for pregnant women.

Dr. Samarasinghe was in the middle of a Caesarean section when the first of three massive waves slammed into the Maternity Hospital in the south coast city of Galle. The electricity was knocked out immediately along with the emergency generator. “It sounded like a freight train coming straight through the ground floor,” he recalls.

Frantic nurses and other medical staff began evacuating over 350 terrified women and newborn babies from the sprawling three-storey facility. The second and largest wave reached nearly to the second floor, where Dr. Samarasinghe was completing the operation by flashlight. He calmly finished, then helped the woman and her baby to safety through a back door.

Walking through the shattered shell of the largest maternity hospital in the city, it is hard to image how the staff managed to save 379 patients and their babies by getting them to higher ground. Remarkably, only one infant was lost in the chaos.

In the aftermath of the 26 December tsunami, mangled beds are wedged against pockmarked walls; windows are blown out as if from an explosion; and equipment, such as blood transfusion units and X-ray machines, lie in twisted heaps. A washing-up sink, torn completely from the wall, ended up outside the main entrance in a pile of debris.

One of the immediate tasks confronting Sri Lanka's health system is coping with the reproductive health needs of pregnant woman, mothers with newborn infants, and adolescent girls. Some 15,000 pregnant women in the tsunami-affected areas will need access to reproductive health services and emergency supplies in the coming weeks.

With many of Galle's health facilities damaged or destroyed, the district's teaching hospital set up a special maternity ward. However, it can accommodate no more than 47 patients. It is now coping with over 300 women at any given time. The halls and resting rooms are so overcrowded that women in labour are stretched out on floor mats side by side while waiting to give birth. Doctors and nurses have been working around the clock since the disaster. Over 600 women have given birth in this facility since the tsunami struck. Not one baby has died.

“We are coping as best we can,” says Dr. Priyanee Senadheera, director of the destroyed Maternity Hospital. “But we are rapidly running out of essential supplies. UNFPA's emergency assistance has arrived just in time. Frankly, I don't know how we would manage in the coming weeks without this assistance.” The first shipments of reproductive health supplies, including emergency obstetric kits and safe birthing supplies, have already reached Galle and other hard-hit coastal regions. The first of several convoys unloaded seven tons of emergency supplies at Galle's teaching hospital. From here, the supplies are distributed to hospitals and clinics throughout the district.

So far, UNFPA has mobilized $4.4 million in emergency assistance to Sri Lanka, but there remains a significant shortfall in resources. “Our emergency assistance is aimed at meeting the reproductive health needs of women, safeguarding their maternal health, as well as providing psycho-social counselling for survivors and addressing gender violence in temporary shelters,” points out Lubna Baqi, UNFPA Representative in Sri Lanka.

Rebuilding the country's health infrastructure will take time and cost around one billion rupees ($10 million), according to the Health Ministry. Looking after the needs of women and girls is a very important part of the relief operations that the Ministry is coordinating. “One of our main priorities in this crisis is meeting the reproductive health needs of women and adolescent girls,” insists Nimal Siripala de Silva, Sri Lanka's Minister of Health. “UNFPA is playing a critical role in this operation. They have helped us a great deal in the aftermath of this disaster.”

Back at the Galle teaching hospital, perched on a wooded hill overlooking the city, Dr. Samarasinghe is performing another Caesarean section. He is proud that his staff has not lost one patient since the tsunami. “But we would not be able to maintain sanitary conditions nor provide the medicines and services needed were it not for UNFPA and the other aid agencies that have helped us out in our time of greatest need,” he concludes.

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Emergency Supplies

UNFPA is meeting important but often overlooked needs for women and girls, from hygiene supplies to headscarves.

In the Aceh province of Indonesia, which bore the brunt of the devastation from the 26 December tsunami, UNFPA and partners are working to provide urgently needed sanitary supplies and medical care for pregnant women—often ignored or forgotten during emergencies.

Dr. Trisnawati Loho of the Indonesian Ministry of Health said that the maternity ward at the Kesdam Hospital in Banda Aceh is not functioning. “Aceh's hospitals need portable latrines, medical supplies, hygiene kits, clothing and vitamins, especially ferum tablets to prevent anaemia in pregnant women,” she said.

As devout Muslims, many women in Aceh are reluctant to go out without headscarves. UNFPA therefore provides headscarves as part of the hygiene kits that the Fund distributes in camps. “If women are not able to leave their tents, this will prevent them from accessing other basic services. The headscarves in the packages we provide the women therefore contribute to their mobility,” said Dr. Henia Dakkak, a UNFPA public health specialist.

Dakkak also points out that disasters do not only damage health facilities and ruin supplies, they can also kill and traumatize health personnel, potentially causing a collapse in the health care system in an entire region. The Indonesian Midwives' Association said 30 per cent of its 5,500 members died in the tsunami.

UNFPA has so far distributed about 5 tons of basic hygiene supplies, such as towels, soap and sanitary napkins. The supplies also include medical equipment and medicines to ensure proper prenatal care and safe deliveries. About 14 tons of additional supplies are expected to arrive in Banda Aceh on 21 January. The supplies are distributed in cooperation with national and international non-governmental organizations, including GOAL, the International Rescue Committee, Islamic Relief, Medècins du Monde (Doctors of the World) and Solidaritas Perembuan (Women Solidarity), a Jakarta-based women's group.

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FAMILY PLANNING

UNFPA and partners are responding to increased demand for family planning among couples made homeless by the tsunami.

UNFPA and partners are helping to restore family planning services in Aceh, where doctors and local social workers are reporting an increased demand for contraceptives among the displaced population, as couples seek to prevent pregnancies while they are living in camps.

A medical doctor with the Indonesian National Family Planning Coordinating Board, Tri Tjahjadi, said that his office is experiencing an increase in demand for contraceptives from people in camps in various parts of Aceh province.

He said his office has received 16,000 units of contraceptives—pills, condoms and injectable contraceptives—while the actual need is 80,000. He also said that the Board does not have enough staff and vehicles to distribute available contraceptives.

Under normal circumstances, about 60 per cent of Indonesian couples use contraceptives regularly.

“Many women do not wish to have children while they are living in camps. They are used to getting their contraceptives from their midwives but now they are unable to, either because of lack of supplies, or lack of access to health personnel,” said Lily Puspasari, an expert on gender issues who works for UNFPA, the United Nations Population Fund, in Aceh. As part of its response to the tsunami, UNFPA is providing contraceptives along with equipment, medicines and supplies to ensure safe childbirth and prevent sexually transmitted infections and HIV/AIDS.

Family planning services are important in the aftermath of natural disasters, because they help prevent unwanted pregnancies, avoid pregnancies spaced too close together or dangerous pregnancies in women who are too young or too old, as well as the transmission of sexually transmittable infections, including HIV/AIDS.

Darmiyaty, a 23-old married woman and mother of a 6-month-old boy living in the Lampeuneuruti camp in Banda Aceh, said she cannot afford to have another child. “Not in this situation, because I lost everything.”

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HYGIENE AND WELL-BEING

Emergency hygiene supplies are helping to restore the dignity and mobility of people made homeless by the disaster.

In a quiet, leafy enclave in Sri Lanka's capital, 35 young volunteers work in assembly line fashion putting together emergency hygienic supplies. These supplies are badly needed by women and girls affected by the devastating tsunami that claimed 30,000 lives in this island country and left over 800,000 homeless.

The workers, mostly between 15 and 25, are members of the National Youth Services Council, a UNFPA (United Nations Population Fund) partner organization, with representatives in virtually every community in the country. Some have been working tirelessly since the 29th of December, when the initiative was launched with funding provided by UNFPA.

In a breezy room filled with boxes, the young people work fast and efficiently to assemble the supplies into individual packages. Each contains soap, disinfectant, washing powder, sanitary napkins, ladies panties, a toothbrush and toothpaste, and towels.

In the first mass shipment, 25,000 packages are being trucked to three of the hardest hit districts – Trincomalee, Galle and Hambantota – and one township, Moratuwa. Some 300,000 of these hygienic kits will be sent to survivors in the coming weeks.

Amali Boteju, 17, has been working long hours over the past two weeks to help assemble these emergency supplies. A lively girl with piercing eyes, she feels it is her duty to help out. “Even though my family is safe, my sister lost her home in Moratuwa when the waves came. This tragedy happened to all of us, it happened to the country. Nearly everyone I know has a family member or relative affected by the tsunami. By working together we can make a difference in the lives of those who have lost so much.”

Amali hasn't been back to her secondary school since the tsunami struck on 26 December. Many schools that escaped damage have been converted into shelters for the displaced.

“I intend to work here as long as I can,” Amali insists. “These packages may not look like much, but believe me they mean a great deal to the women who get them.”

On the next table, Sampath Kusumsiri, an athletic coach at the National Youth Centre, is busy stuffing towels and disinfectants into bags, the last items to go in. He too has been working feverishly for two weeks. “I think this effort makes a real difference in the lives of those women affected by the disaster,” he explains in clear English. “We need to show solidarity with the victims. It's important that women get these packages.”

The kits are being distributed by the Ministry of Health's Family Health Bureau and Sarvodaya, a national NGO with 10,000 local branches throughout the country.

“In emergencies like this one, the health needs of women and adolescent girls in particular are often overlooked or ignored,” points out Lubna Baqi, UNFPA Representative in Sri Lanka. In the face of such tragedy, women need very basic supplies, as well as medicines and food. These supplies will safeguard their dignity and allow for mobility, while they try to rebuild.”

At the assembly centre in Colombo, Amali is tired but exuberant. “I will be back tomorrow and as often as necessary to complete this work.”

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PSYCHO-SOCIAL SUPPORT

Counseling and other psycho-social support are helping survivors cope with what they have lost so they rebuild their lives and their communities.

Sitting in a tent in the stifling heat, Latha Wijesiri, a volunteer health worker, talks quietly with four women about their immediate emotional and physical needs. One of the women, the youngest, lost her husband to the tsunami which ravaged Sri Lanka's southeast coast a month ago. The rest have lost relatives and friends. All have lost their homes and livelihoods.

The entire waterfront section of the city of Hambantota was swept away by three massive waves. In the aftermath, 4,500 people perished in this district and thousands were left homeless. Some 500 traumatized survivors, living in tents on the rubble of their fishing community, are now trying to rebuild their lives.

“I was trained in 1997 by UNFPA [the United Nations Population Fund] as a community health worker,” says Wijesiri. “Now following this tragedy, I received special training in psycho-social support as well. I visit these camps several times a week to assess the women's psychological and social needs. And once a week I train other women in reproductive health issues, including counselling.”

Wijesiri is a member of Sardovaya, one of the country's largest NGOs. “We lost 800 of our members to the tsunami,” she sighs. “I feel it is my duty to do as much as I can to help the women of this district to recover and rebuild.”

She also is assessing the security needs of women and adolescent girls living in temporary shelters and tents. “We have received reports of gender-based violence in this district, especially in the days immediately following the disaster, and we are monitoring this situation in the refugee camps very carefully,” explains Wijesiri. “Woman and girls are especially vulnerable in these situations.”

A $610,000 grant from the German Government will be used to address sexual and gender-based violence in Sri Lanka. The grant will also be used to assist victims by providing services, including long-term psychological support.

The Health Ministry has estimated that only 5-10 per cent of survivors will need targeted psychological support, the majority of them women and girls who have lost family members and their homes. However, many thousands will need continued social support. “Some of these women are really in a terrible emotional condition,” points out Wijesiri. “We think that counselling and other forms of emotional support will have to continue for at least six months.”

In the last tent, Wijesiri visits a young Muslim woman sitting alone with her youngest child. She was saved from the waters by her husband. But like everyone else in this former fishing community, she lost her house and all her possessions. She tries to put on a brave smile, but soon loses all composure. When asked what she expects in the future, she replies simply: “nothing.”

Wijesiri makes a note of her name and tent number. “This woman is going to need a great deal of support,” she says. “I hope that I can give her some measure of hope for the future and help her regain her life. There are many women like her.”

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INDONESIA

In January, at the request of the Ministry of Health, UNFPA deployed a team of four technical staff to assess the reproductive health situation in Aceh, the area hardest hit by the disaster. Among their findings:

  • Demographic shift – Women and children seem to constitute a disproportionate number of those who lost their lives, in part because they were closer to shore while men were off at work when the tsunami struck. A head count in one camp found 400 men between the ages of 18 and 55 but only 274 women in the same age group.

  • There is still no accurate data on the number of IDPs living with relatives and host communities. Since these people would not have registered at temporary shelters, official figures of people who will eventually require medium- and longer-term assistance may be low.

  • There is no accurate information on households that, as a result of the tsunami, are now headed only by a woman who lost her husband, or a husband who lost his wife. Each of these single-parent household situations has different implications for assistance planning.

  • EOC: Only one of Banda Aceh's three provincial hospitals still has the capacity to do a C-section. The referral system for EOC has collapsed and is not in place for either IDPs or the general population of Aceh.

  • Health personnel are not only overwhelmed but their numbers are reduced, as many died, and survivors are likely to be suffering the trauma of their own losses.

  • RH commodities are not available at the moment. The Singapore military contingent has approached UNFPA requesting RH kits for their own team as they had not taken RH issues and needs into account when planning their response. Lifesaving drugs needed for EOC are not available within the drugs and supplies provided by foreign teams and hospitals.

  • Women's needs are immense, and include: impeded mobility due to lack of headscarves; not enough water for IDP women to do chores; lack of underwear; lack of antenatal care for pregnant IDP women; need for female providers for FP and gynecological services; not being consulted on camp management issues; fear of using latrines at night due to lack of electricity; extra burden due to lack of humanitarian attention to the needs of the elderly.

  • Minimum needs for healing are not being met. People are severely traumatized and want to pray but large numbers report that a lack of headscarves and Korans is preventing them from doing so.

  • Impact of curfew on EOC: There is now a curfew between the hours of midnight and 5 a.m., which means no movement of the personnel and vehicles that would normally convey emergency obstetric cases during these hours.

UNFPA tsunami response in Indonesia includes:

  • Deployment of 18 tonnes of hygiene kits, medicines, medical equipment, and supplies to meet the needs of women and youth, particularly the health needs of pregnant women.

  • Distribution of hygiene kits and medical supplies: Working with local and national NGOs, UNFPA has facilitated the distribution of hygiene kits, medicines, medical equipment and supplies in camps for people displaced by the disaster. The supplies have been distributed to camps in and around Banda Aceh. UNFPA's partner organizations in the distribution include BKKBN, Islamic Relief, GOAL, the Indonesian Ministry of Health, the International Rescue Committee, Medecins du Monde (Doctors of the World), and Solidaritas Perembuan (Women Solidarity), a Jakarta-based women's group.

  • Psychosocial support: UNFPA plans to offer counseling and other psychosocial services to the victims of the tsunami through the establishment of ten community support centres to be set up in the hardest hit districts of Aceh province. The centres will be established and run in cooperation with a number of partners, including the Indonesian Psychologist Association and the Indonesian Ministry of Health.

  • Gender-based violence: In an effort to prevent violence against women, UNFPA has been promoting safe access for women to basic services, and will be providing training in gender-sensitivity for government officials and community leaders in the temporary settlements.

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SRI LANKA

On-going assessments by UNFPA have revealed the following:

  • Damage to health facilities and services - The health infrastructure sustained over one billion rupees ($10 million) in damages. The government is moving quickly to rebuild and restore facilities. In the meantime, some hospitals must cope with three times the pre-tsunami volume of patients. At an institutional and structural level, more than 22 hospitals providing essential and emergency obstetric care services were completely destroyed and 6 were partially damaged. In addition, PHC services for women and children are also badly affected as quite a number of clinic buildings have been damaged. The sudden displacement associated with this disaster has forced many women to discontinue their family planning methods.

  • Gender-based violence - UNFPA partners – including the National Committee on Women, the Women's Media Collective and Sarvodaya, one of the largest grassroots NGOs in the country – are working to verify reports of sexual and gender-based violence in temporary shelters. A limited number of cases of sexual abuse have been reported so far, but with women and children constituting the majority of people in shelters, the situation needs close monitoring.

  • Psycho-social support - Health Ministry officials say that targeted psychological interventions should be considered for an estimated 5-10% of the affected population.

  • Livelihoods - At least half a million are out of work due to the tsunami. The tourism industry in the southern and eastern regions of the country has been hit especially hard. There are no estimates available as to the number of women who have lost their livelihoods, but Sarvodaya is gearing up its training activities and micro-credit schemes in an effort to help put affected women back to work.

UNFPA tsunami response in Sri Lanka includes:

  • UNFPA is assembling 300,000 hygiene packages and is dispatching them to some of the hardest hit regions in the south, east and north. The packages contain: soap, disinfectant, washing powder, sanitary napkins, underwear, toothbrushes and toothpaste and towels. These packages are being distributed through Sarvodaya and the Family Health Bureau. Communities receiving hygiene packages so far include Hamabantota, Trincomale, Col-Moratuwa, Col-Dehiwela, Col-CMC, Galle, Matara, Ampara, Ampara-Kulmunai, Kalutara, Gampaha, Vavuniya, Batticaloa, Mullaitivu, Killinochchi, Kalmunai, and Matara-Tangalla.

  • Emergency RH medical supplies have been provided to hospitals and regional medical stores in Galle, Batticaloa, Trincomalee, Matara, Ampara, Kalmunai, Hambantota, Kilinochchi, Mullativu, Jaffna, and the Family Health Bureau and the Central Blood Bank in Colombo. These supplies include materials to facilitate administration and training activities, individual delivery packages to ensure pregnant women have a clean delivery, contraceptive methods, drugs to treat STIs, equipment and supplies for midwives to conduct normal deliveries and to stabilize patients with obstetric complications, including materials to suture cervical and vaginal tears, medical equipment and supplies to perform caesarean sections and to treat other obstetric complications, and ensure safe blood transfusions. An ultrasound scanner and a CTG machine are also being provided to Mahamodera teaching hospital; additional equipment will be procured as per the request of the Ministry of Health.

  • Twenty-five tents have been ordered and will be used as makeshift clinics for RH and family planning services in areas where the clinics have been destroyed. This is a stopgap measure until such time adequate buildings and resources are set in place.

  • The Ministry of Health is providing training to existing staff to build their capacity to respond to psychosocial needs through a UNFPA-sponsored programme focusing on women and girls. UNFPA has also agreed to edit and translate into local languages the booklet Guidelines for Health Workers Providing Psychosocial Support to Persons Affected by the Tsunami Disaster , which was produced immediately after the disaster in collaboration with the Directorate of Mental Health Services, and circulated among health workers at the district level.

  • Gender issues, including SGBV: UNFPA is helping to improve monitoring systems and information management relating to gender issues to enable the institutions to better respond to the emerging needs of women and girls. UNFPA will also support the creation of safe spaces in displaced communities where women and girls can have access to a range of services and referral pathways for inter-sectoral support mechanisms according to their need. Other UNFPA activities to minimize and address SGBV have included direct training of frontline workers and the editing and translation of training modules.

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MALDIVES

Two UNFPA assessments have been conducted – one 5-7 January, and another 12-14 January – based on visits to several different atolls and islands. Among the findings:

  • Damage to health facilities – On the worst hit islands, nearly everything will have to be replaced. Loss of medical records, food supplements for pregnant women, vaccines and contraceptive stores pose challenges as well. Over 30 health service delivery facilities have been damaged and a number severely damaged so that they are no longer functioning. In the case of islands that were severely flooded, damage to both physical plant and equipment has been considerable, and especially so with respect to equipment. Few facilities on the most affected islands will be able to function without major (and in some cases total) re-equipping. In most cases even the heaviest of equipment had been moved around by the tsunami and in many instances had been washed out of rooms. This includes refrigerators, sterilisation units, incubators, operating theatre equipment, delivery and ward beds. Most of this equipment, especially electrical equipment, is beyond repair and will need to be replaced.

  • Supplies - Stores were also damaged and all medicines and disposables were lost in most of the facilities that had been flooded. Contraceptives, food supplements such as folic acid and calcium for pregnant women were lost.

  • Pregnancy - Contrary to expectations, no reports on the islands visited of increased complications of pregnancy or higher than usual miscarriage, premature delivery, low birth weight or peri-natal distress. This is not to say that problems of this nature will not emerge in the weeks to come; health staff members need to be trained to recognize complications requiring evacuation to islands with capacity for emergency obstetric care. Another issue is malnutrition, which was already a problem before the disaster and is particularly of concern for pregnant and lactating women and children.

  • Psychosocial - Shock, fear, withdrawal, nightmares, and loss of sleep and appetite have been reported to varying degrees and appear widespread among displaced and non-displaced alike. While this is to be expected in the short term, it could be problematic at both clinical and public health levels over time.

  • Adolescents – Some reports of worrisome and risky behavior among displaced adolescents in temporary settlements.

  • Economic livelihoods – These have been seriously affected, which contributes to psychosocial impact. Fishing is main source of income on most of the islands and even where boats have not been damaged some men are now reluctant to take to the sea again. Women's livelihoods, including weaving of products sold to tourists, have also been affected.

UNFPA tsunami response in the Maldives includes:

  • UNFPA has been working with UNICEF, WHO and UNDP to draft the sections on gender, on health, and on the protection of women and children for the World Bank/Asian Development Bank joint assessment.

  • RH supplies have been distributed to 14 of the hardest hit islands, covering seven atolls. UNFPA is monitoring the distribution together with the Ministry of Health. UNFPA has also arranged for expatriate medical support to MoH-run health facilities (one psychiatrist, one surgeon and two gynecologists).

  • UNFPA arranged for a regional gynaecologist to perform antenatal checkups for pregnant women on the three hardest hit atolls.

  • At the Government's request, UNFPA has been overseeing the production of mother-baby kits, and has procured 100,000 sanitary napkins, to cover the needs of affected women for one month.

  • UNFPA is supporting the travel of counseling teams to provide psychosocial support to the communities most affected by the tsumani. In this regard teams have already traveled out to five atolls. Briefings on psychosocial support have also been provided by UNFPA technical experts for health service providers, including a briefing for medical doctors and nurses at the Central Hospital.

  • UNFPA training on psychosocial care has been provided to hospital staff.

  • Discussions are underway with UNDP for recruitment of a gender specialist.

  • A series of notes on breastfeeding, pregnancy and management of IDP camps has been prepared and is being translated for distribution to all affected islands. In camps visited by UNFPA, the Fund has met with camp managers to emphasize the importance of separate facilities for women, lighting and other security issues, hygiene, and the special needs of adolescents and the elderly.

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THAILAND

A UNFPA assessment was undertaken in mid-January to assess reproductive health needs – with special attention to emergency obstetric care, psychosocial needs and gender concerns – among Thais and migrant workers affected by the tsunami. Provinces visited: Ranong, Phang Nga, Krabi and Phuket. Among their findings:

  • Health systems, including RH services, are intact but motivation to use the services has decreased in severely affected communities. Moreover, many health centres have been used as command centres for emergency response, resulting in inconvenience for regular clients.

  • Effects on migrant workers have not been well recorded. In Phang Nga province, more than 5,000 workers were missing, 800 had moved back voluntarily and 500 were arrested and sent back to Myanmar.

  • Greater psychological support for adults, especially for men who have lost their loved ones and/or their jobs, is needed.

  • No evidence has been found of increased vulnerability to abuse among women and girls. The fact that many pregnant women were able to move out of the affected areas indicates good support for women.

  • Data systems are fragmented and limited. Each sector seems to be collecting data related to its own mandate only and there is no consolidated database.

  • Emergency obstetric care does not seem to be a problem as most pregnant women in Ranong, Phang Nga and Phuket have moved out of the areas. Only communities on the island of Lanta may require emergency obstetric care in the next couple of months. As reconstruction activities get underway, however, pregnant women may move back so damaged or destroyed facilities must be restored quickly.

  • Family planning services are available but there is a need to ensure that displaced persons who were using these services before the disaster are aware of how and where they can continue.

  • No evidence was reported of unequal access to services by women, but more in-depth interviews with displaced women are needed.

  • Demographic issues: As several hundred thousands Thais and migrant workers have been directly affected and new communities will be constructed, there will be substantial demographic changes in the affected areas. Migration both in and out of these areas will alter job opportunities. In the emergency phase, construction work will predominate. During the post-emergency and transition period, job training will be needed for new workers moving in for the reconstruction of local tourism and fishery business. Some cross-border migrant workers will bring their family members along, which will result in changing population structures in these areas.

As part of its tsunami response in Thailand, UNFPA plans to expand its collaboration with the Ministry of Health and NGOs to ensure quality maternal and child health and family planning services in newly constructed communities for those displaced by the tsunami, including migrant communities. These efforts will focus on improving access to information, counselling and services, at both health centres and mobile clinics, and on training health providers and community volunteers to provide trauma-related counselling and to address reproductive health concerns including safe motherhood, family planning, gender equality, HIV prevention, and adolescent health.

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UNFPA is the world's largest multilateral source of population assistance. Since it became operational in 1969, the Fund has provided sustained assistance to developing countries to address their population and development needs. For more about UNFPA, visit http:/www.unfpa.org. For questions or comments about Frontlines, send an e-mail to frontlines@unfpa.org.