Safeguarding Reproductive Health and Rights in Humanitarian Emergencies
War, natural disaster and forced displacement take a heavy toll on the reproductive health of adolescent girls and women. Sudanese women fleeing combat had to give birth without even the barest essentials for clean delivery, such as a fresh razor blade and soap. This condemned many to fatal infections,(50) and their children to a life without a mother's love and support. One in nine of these women were estimated to die in pregnancy or childbirth in 2003.(51) The death of a widow also deprives her children of their primary provider of food, shelter and health care.
Safeguarding reproductive health and rights in humanitarian emergencies is fundamental to saving lives and laying the foundation for gender equality and sustainable development when stability returns. Until fairly recently, however, reproductive health care was seldom available during emergencies. In 1995, a coalition of UN agencies, governments and non-governmental organizations formed the Inter- Agency Working Group on Reproductive Health in Refugee Situations. This group produced a field manual for humanitarian operations that outlined a package of critical interventions to prevent maternal mortality and HIV infection and guarantee access to family planning.(52) The Reproductive Health Response in Conflict Consortium, a network of international humanitarian non-governmental organizations, also works to improve reproductive health care during emergencies.(53)
Protecting maternal and infant health is now becoming a critical element of relief efforts. In the past five years, UNFPA and its partners have provided clean delivery kits in more than 30 countries, from Liberia to Timor-Leste. Since 2003, UNFPA has worked to strengthen primary health centres and has made emergency reproductive health supplies available in Iraq.(54) In 2005, UNFPA distributed clean delivery and personal hygiene kits to displaced women in parts of Indonesia, the Maldives and Sri Lanka that were hardest hit by the tsunami. Support was also provided to re-establish obstetric care in hospitals throughout the region.(55)
Humanitarian crises disrupt women's access to family planning services and expose them to unintended pregnancies, unsafe abortion and sexually transmitted infections, including HIV. In emergency settings, relief organizations increasingly supply free condoms as the first line of defence against unintended pregnancies and the spread of sexually transmitted infections, including HIV. In 22 waraffected countries, UNFPA and the Office of the United Nations High Commissioner for Refugees (UNHCR) are working together to provide male and female condoms in displacement camps.
"At my parents' house, seven men
raped a widow who was staying
with the family. The men said, 'At
least one of us must be HIV
positive.' The widow contracted
AIDS, and she has already died."
- A survivor of the Rwandan genocide
After an acute emergency winds down, UNFPA and its partners continue to support governments to sustain reproductive health care programmes. In Burundi, for example, the Ministry of Health developed standards for reproductive health services, including for emergency obstetric care. Support was provided to train midwives and physicians, equip hospitals serving displaced people and educate communities on the need for skilled care during deliveries.(56) Following earthquakes in Turkey (1999) and Bam, in the Islamic Republic of Iran (2003), mobile medical teams were deployed to deliver reproductive health care.
The particular challenges that Palestinian women face in Gaza and the West Bank face has been a top priority for UNFPA. Since even before the escalation of conflict in 2000, an estimated one fifth of pregnant women could not receive prenatal care because of the difficulty of travelling through checkpoints to health facilities. Delays at checkpoints have resulted in unattended roadside births and even the deaths of some women and infants. UNFPA is working to provide access to life-saving emergency care.(57) As part of a larger effort to improve the well-being of women in underserved areas, UNFPA has been involved in establishing women's health centres that offer reproductive health care as well as other needed services, including psychosocial counselling, legal aid on reproductive rights, and support for women's rights within the family.
MENDING LIVES, ADDRESSING SEXUAL VIOLENCE. Millions of women have been raped and sexually tortured during conflicts. Rape camps, sexual slavery, and forced impregnation or intentional infection with HIV have all occurred in recent conflicts.(58) In Rwanda, sexual violence during the genocide triggered the country's HIV/AIDS epidemic: It is estimated that a half million girls and women were raped and that 67 per cent of them became infected with HIV.(59) During the 1991-2001 conflict in Sierra Leone, young girls were specifically singled out for rape. Many, particularly the very young, did not survive.(60) In the same country, an estimated 70 to 90 per cent of rape victims contracted sexually transmitted infections.(61)
Even when women fleeing conflict find their way to refugee camps, they are not necessarily safe. In one Tanzanian camp, 26 per cent of women refugees from Burundi were raped.(62) It is not uncommon for family members and the community at large to ostracize the victims of rape, at times forcing them out of the home and leaving them to fend for themselves. Survivors of rape often face severe life-long problems, including persistent post-traumatic stress and debilitating depression.(63)
Humanitarian organizations are supporting educational campaigns to reduce violence against women, including installing safety measures; training community leaders, police and judges; and improving law enforcement. The importance of reaching men is also recognized: The International Rescue Committee (IRC) now routinely forms men's committees to raise awareness and support survivors of violence.(64) Despite initial community resistance, an IRC initiative in Burundian refugee camps in the United Republic of Tanzania led to the use of mobile courts to enforce laws on genderbased violence. The programme is now sustained by community support and also offers awareness training, a reporting and referral system, counselling and health services and a 24-hour drop-in centre.(65) In the Darfur region of Sudan, UNFPA supports women's organizations that assist survivors, supply medical equipment, work to make refugee settlements safe, and train medical professionals to manage cases of sexual violence.(66) Reports of abuse and exploitation of girls and women, such as in the Democratic Republic of the Congo and Liberia,(67) have furthermore led the UN Department for Peacekeeping Operations to develop new guidelines to reduce the possibility of sexual violence and exploitation by peacekeepers and uniformed personnel working in humanitarian relief settings.(68)
35 | MOBILIZING TO STOP VIOLENCE AGAINST WOMEN IN TIMOR-LESTE
Since gaining independence in 2002, Timor-Leste, though still one of the poorest countries in Asia, is taking a stand for gender equality. Women leaders, who had been active during the struggle for independence, pressed for policy attention and equal participation in political institutions established since independence. Now women hold 27 per cent of parliamentary seats, and an Advisory Office to the Prime Minister for the Promotion of Equality has been created.
The women's movement identified gender-based violence as a top priority. UNFPA sponsored the country's first reliable study, which revealed that 50 per cent of women had experienced some form of abuse. A National Police report indicates that violence against women constitutes 68 per cent of all cases received. The police are being trained to protect and support victims. Mass awareness-raising efforts and campaigns using drama, radio programmes and a television soap opera have opened widespread discussion on a formerly taboo subject, and a new domestic violence law has raised the issue's public profile.
With UNFPA support, Timor-Leste set up its first legal support services for abused women, and the first hospital "safe room", where women receive medical care and counselling in private. The Association of Men Against Violence has held social education workshops with men living in remote and rural areas and has provided anger-management training for male offenders in the national prison.
HALTING THE SPREAD OF HIV. Conflict, displacement and the resulting loss of access to health services and information can increase the possibility of HIV transmission. In the Democratic Republic of the Congo, for example, 5 per cent of the population was HIV-positive before the war erupted in 1997. In 2002, that estimate spiked to 20 per cent in the eastern area of the country where the conflict began.(69) The near-total collapse of security and social protection systems, the high incidence of rape and lack of safe blood supplies undoubtedly contributed to these increases. Situations in which a major military or militia presence routinely mingles with the civilian population can create additional risks because military forces tend to have higher rates of sexually transmitted infections, including HIV, than civilian populations.(70) If HIV prevalence is already rising, conflict can be the spark that ignites a full blown epidemic. The end of conflict does not mean the end of risk. Conflicts bring in their wake lasting social disruption, loss of familial and community protection from sexual exploitation and abuse, and the collapse of preventive services. Many women and girls are forced into transactional sex simply to survive.
With rising international awareness about the impact of armed conflict on the AIDS epidemic, humanitarian relief efforts are integrating prevention and treatment earlier in their work. UN system and reproductive health networks operating in emergencies are issuing guidelines for humanitarian workers.(71) Many organizations are specifically targeting men, particularly within disarmament, demobilization and reintegration programmes. In Eritrea and Ethiopia, for example, UNFPA supported the training of demobilized soldiers on HIV prevention and counselling, so that when they returned home, they could educate others in their communities.(72)
In Liberia, UNFPA helps a broad coalition of nongovernmental organizations undertake massive awareness-raising campaigns aimed at displaced populations living in refugee camps-particularly where large numbers of women and girls have turned to commercial sex to survive. Community-based organizations operating along the borders with Sierra Leone and Guinea have now educated 60,000 displaced persons and returnees on the prevention and treatment of sexually transmitted infections including HIV, and 3.2 million male condoms have been distributed. Some 5,000 peer educators have reached schools, camps and communities with HIV-prevention education. People living with HIV and AIDS are also being recruited as "Prevention Ambassadors". There are weekly training sessions for UN peacekeepers on sexual violence and the prevention of sexually transmitted infections and HIV. These intensive efforts have broken the silence, denial and stigma surrounding the AIDS epidemic. More people are seeking counselling and treatment.
Peacekeeping operations can also help to educate recovering societies about risks and play a positive role in HIV prevention. The UN Department of Peacekeeping Operations (DPKO) now works hand in hand with UNAIDS to include HIV prevention advisers in each mission and has set up an HIV/AIDS Trust Fund to support its programmes.(73) In Sierra Leone and the Democratic Republic of the Congo, DPKO, UNAIDS, UNIFEM and UNFPA work together on HIV prevention and gender awareness for peacekeepers and the newly established army and police forces.(74) Recognizing the increase in regional peacekeeping operations, the US Department of Defense allocated $14 million in 2002 for HIV prevention programmes specifically for African armed forces.(75)
INITIATIVES FOR YOUNG PEOPLE. Following a crisis, involving young people in reproductive health programmes is essential in order to slow the spread of HIV and reduce unwanted pregnancies. The Women's Commission for Refugee Women and Children supports youth-led programmes in areas affected by conflict.(76) In the United Republic of Tanzania, UNHCR established youth-friendly centres in refugee camps, run by youth-led committees, in order to address reproductive health issues and provide services, produce media campaigns and offer vocational skills training and information on how to care for HIV-affected relatives.(77)
UNFPA, with Belgian support, is working with local partners to provide reproductive health services to young people in selected countries (see Box 36). In Rwanda, UNFPA has supported the establishment of youth-friendly health centres where young people learn about HIV prevention and other reproductive health issues. The centres also offer training on income-generating skills such as producing soap, handicrafts and embroidery, and opportunities for participation in cultural and sports activities.(78)
36 | THE HEALING POWER OF THE ARTS:
WORKING WITH DISPLACED ADOLESCENTS IN COLOMBIA
In Colombia, where at least two million people have been displaced by the 30-year internal conflict, UNFPA, with assistance from Belgium, has supported an innovative approach: artistic expression as a release and remedy for the violence in adolescents' lives. Since 2003, the project has worked with displaced adolescents in cities on the Caribbean coast, where sexual violence is rampant and impunity is the norm. Displaced girls there are three times more likely than their peers to become pregnant before age 15. Drawing on adolescents' creative energy, the programme uses drama, role-playing, music and dance to encourage them to recount the trauma they have experienced. Health providers visit twice a week to talk about reproductive health and prevention and offer services. Participants in the programme acquire the tools to challenge harmful aspects of gender relations, resist peer pressure, address sexual violence and raise their self-esteem.
In Egypt, Uganda and Zambia, the Health of Adolescent Refugees Project worked in partnership with Girl Guides who served as peer educators to advise health providers on adolescents' needs. Providers are trained by medical personnel on key aspects of reproductive health. The initiative has increased young people's self-confidence and sense of solidarity.(79)
Initiatives such as these are mostly incipient and rare. But they hold the promise of empowering young people to contribute to their countries' road to recovery, peace and prosperity, to the MDGs and beyond.