Menstrual Hygiene Management in Refugee Camps
By Josie Newman
April 19, 2016
Back in 2012, the International Federation of Red Cross (IFRC) began a pilot project to provide refugee women in the Burundi, Bwagiriza refugee camp with menstrual hygiene management kits and to improve understanding of such needs in emergency situations (Bayisabe). However, the IFRC press release on this program gave no specifics on what the kits would include or how they would be distributed. Furthermore, the last recent publication by the IFRC on this topic was November 4, 2013 which announced a grant that would allow for more menstrual hygiene management in emergencies (Onyango). What that would entail was not specified nor has any report been given on the success of the program. Why so few details were included in regards to this program is unsure; however, in many cultures female menstruation is rarely discussed as it is viewed as a taboo topic; even in western culture the topic is rarely spoken about in public. As taboo, the issue of female menstruation in refugee camps has become an, “invisible, inaudible, and secondary” (Wanga-Odhiambo 52) issue only adding to the struggles faced by women in refugee camps. According to the UN Refugee Agency (UNHCR) women in refugee camps have an increased risk of, “discrimination and sexual and gender-based violence” (“Women”). These women are also prone to many life-threating diseases in the camps (Sinha). As outlined in the UNHCR’s Commitment to Gender Equality aid organizations strive, or ought to strive, to ensure the, “rights, protection, services and resources” of women so that they might, “participate as active partners in the decisions that affect them.” However, on the UNHCR’s website and all other aid organization websites such as: Doctors without Borders, International Rescue Committee, Refugees International, and the U.S Committee for Refugees and Immigrants, very little is said, if even mentioned at all, on the organizations’ menstrual hygiene management (MHM) plan. Yet, poor MHM has a direct impact on the health and equality for women in refugee camps; therefore, refugee aid organizations should partner with women’s health organizations to address this problem.
The greatest challenge in providing the tools necessary for proper MHM, which include both pads, and hygienic education, is that the topic of female menstruation is one that few people like to talk about. Even with the political, economic, and social gains made my women in the first world, the topic of menstruation is still very restricted (Kissling 1). In western culture media, shame and secrecy lurk beneath even the most progressive messages about menstruation. Never are pads or tampons shown in bathrooms, where they are used, nor is blood ever shown or even mentioned. Advertising is only used to promote the concealment of menstruation, and according to Elizabeth Kissling, author of Capitalizing on the Curse: The Business of Menstruation, “the very term feminine protection, used only in advertising, implies menstruation is something that women must be saved from.” (Kissling 5)
With the lack of discussion around female menstruation, women outside of western culture do not receive the education or resources necessary to practice proper MHM. Furthermore, menstruation in many third world countries carries with it myths and taboos that often lead to unsafe practices in MHM. Elizabeth Kissling explains that in cultures across the globe, menstruation is viewed as, “either an illness to be managed or a hygienic crisis to be cleaned up and hidden.” Those who cannot easily “hide” their “illness” or “hygienic crisis” become restricted in their mobility. Across the globe girls’ daily lives are put on hold a week out of the month as they hide away to deal with their periods. This effects their ability to gain an education and limits the time they can spend working, which then only widens the gender inequality gap that already exists in many of these cultures.
In study published in the 2014 edition of the Disaster Prevention and Management Journal (Carter), 50 women in Uganda were interviewed, and focus group discussions were held in villages, schools, and refugee camps about MHM. The article concludes that although MHM is a constant problem in both villages and schools, women in refugee camps were at a significant disadvantage as they had less access to materials including soap, underpants, absorbing cloth, and facilities like latrines and bathing shelters. Furthermore, in refugee camps the lack of education about menstruation and reproductive health was greater (Carter). A women in the Aketa refugee camp described what materials were used in place of sanitary pads, “We use old clothing, but if we don’t have any we take rags that somebody has dropped in the rubbish pit”(Carter). In most of the villages women use cloth that is then washed and hung to dry. Yet, even this practice is not very effective as the cloth is a poor absorbent, leaks and is often uncomfortable. Wealthier women can buy pads and underpants, but even those are scarce in the markets. It was reported that in some camps NGO’s had provided cotton cloth to be used to absorb blood, but lacking soap and basins to wash the cloth in they often deteriorated quickly and were not replaced, thus the women had to resort back to rags (Carter).
Not only are women in refugee camps forced to use unsanitary materials to absorb menstrual blood, but the lack of privacy and washing resources causes another slew of health and psychosocial problems. In the same article published in the 2014 edition of the Disaster Prevention and Management Journal, a refugee women in the Amursia refugee camp stated:
“In the villages we had freedom and space to dry the rags outside the huts. Here [in the camp] we have no privacy to dry the rags, we are forced to hang them in the house. We also have to wait until evening to wash the rags.”
Lack of privacy and drying facilities lead to women wearing damp cloths. The article cites reports from medical professionals that the, “repeated use of damp cloths leads to health problems such as rashes, fungal infections and UTIs. Damp cloth also rubs against the skin causing open sores, which are vulnerable to infection.” (Carter)
Extensive research in poor MHM regions of the world and their effect on vaginal infections have been conducted, and support the need for proper MHM in refugee camps. Among the studies, poor MHM has been linked to Bacterial Vaginosis (BV), and Reproductive Tract Infection (RTI). Bacterial Vaginosis is when different types of vaginal bacteria outnumber the normal and beneficial bacteria (Health Reference Series 184). Reproductive Tract Infection is any infection in the reproductive tract (Lloyd) and can be caused by the overgrowth of bacteria in the vaginal area (Burnett). With little access to hygienic materials to manage menstruation women in refugee camps have been reported by medical staff to have fungal infections in the vaginal area (Carter).
In a study published by the Bangladesh Journal of Medical Science, RTI was studied in relation to MHM (Kandpal). 453 girls between the ages of 15-18 in Dehradun India were interviewed about practices used to maintain menstrual hygiene, problems related to menstruation and symptoms related to RTI. Of the girls found to have unsatisfactory MHM, 88.2% described the symptoms of RTI, of the girls found to have satisfactory MHM, only 16.1% described symptoms of RTI.
In another study published in the Oman Medical Journal (Bahram), 500, non-pregnant, married women were studied for the prevalence of RTI and its causes. Vaginal exams were conducted to see if the women had RTI. The prevalence of RTI among the 500 women studied was 27.6%, “out of which 16.2% was devoted to bacterial vaginosis (BV), 6.6% to trichomoniasis and 4.8% to Vulvovaginal candidiasis . . .” Of the women who claimed to be always using sanitary pads, 76.8% did not have BV. Of the women who claimed to never wear sanitary pads, 55% had BV. Furthermore the women who always changed their pads after each urination, 83.5% did not have BV, whereas the women who never changed their pads after each urination, 33.7% had BV. It is important to study BV and the factors affecting its prevalence because in multiple studies BV is the most prevalent in RTI. Studies of women in Shandong China, Hamedan Iran, Vientiane Laos, and Northeast Brazil all conclude that BV was the greatest factor in the prevalence of RTI (Bahram).
The Department of Disease Control at the London School of Hygiene and Tropical Medicine (Sumpter), investigated the effects of MHM on health by reviewing all published scientific articles on the topic. They concluded that RTI does indeed have an association with poor MHM, but “the strength and route of the infection is not known.” Therefore, it is important to keep in mind that poor MHM may put a women at higher risk of RTI, but may not be the cause. Thus, more research ought to be conducted in this area, as untreated RTI can have serious consequences. According to the Center for Disease Control and Prevention, thousands of women die each year from undiagnosed or untreated RTI’s, which include,
“Cervical cancer, ectopic pregnancy, acute and chronic infections of the uterus and fallopian tubes, and puerperal infections. Other sequelae include infertility, fetal wastage, low birth weight, infant blindness, neonatal pneumonia, and mental retardation.” (Burnett)
The fact that MHM has a correlation with RTI is a cause for increased MHM education and awareness to help provide proper MHM to refugee women who are at the highest risk of infection.
Poor MHM is also accompanied by psychosocial impacts on women, as menstruation is a gender equality issue, “The way society deals with menstruation may reveal a great deal about how that society views women.” (Kissling 2) Christine Khamasi’s testimonial about the psychosocial impacts of not having access to proper MHM highlights the vulnerability of these women. Christine grew up in Nairobi Kenya, and started menstruating at age 12. One day at school her period came and soaked her dress in blood so that she had to return home. There were no rags available for her to use, so she would use leaves; however, they did little and so she would miss school three days a month. In her own words, “the male teacher saw a weak spot. So, they gave me money for sex to get pads. Life was hard. Even my close relatives could rape me now.” At 14 she became pregnant and had to drop out of school (Spelman). Without access to proper MHM women and girls are placed in vulnerable situations, often resorting to “survival sex”, a term used by the UNHCR, to provide for their families, and in Christine’s case- pads.
In a survey among Burundian refugees in a Tanzanian camp it was identified that 26% of the women had experienced sexual violence since becoming a refugee. In the same survey it was found that most of the incidents occurred within the camp and that the primary perpetrators were fellow refugees living in the camp. (Goodyear, Nduna) In a Kenyan camp risk of sexual assault came from the camp design; latrines were built at the end of camps. Using the facilities at night placed women and girls wishing to use them at high risk of assault. (Wanga-Odhiambo 52) For women and girls on their periods and without proper MHM, latrines are a necessity as it is often the only private place they can wash their bodies clean from menstrual blood. By providing proper sanitary materials to refugee women and girls, who are already at a high risk of rape, such vulnerability could be greatly reduced.
Along with placing women at a higher risk of sexual assault or abuse, lack of proper MHM education and materials restricts a women’s mobility for up to a week each month having a direct impact on girls receiving an education. In regards to how a girl’s education is linked to gender equality, the United Nations International Emergency Children’s Fund (UNICEF) stated;
“Girls’ education is both an intrinsic right and a critical lever to reaching other development objectives. Providing girls with an education helps break the cycle of poverty: educated women are less likely to marry early and against their will; less likely to die in childbirth; more likely to have healthy babies; and are more likely to send their children to school.” (Girls’ Educations and Gender Equality)
Education in achieving gender equality, is a goal for most refugee aid organizations. It is a value for UNHCR, Doctors without Borders, International Rescue Committee, Refugees International, and the U.S Committee for Refugees and Immigrants. All of these organizations acknowledge that education is a vital part in achieving that equality. Yet, there still remains 63 million girls out of school in the world (Girls’ Education and Gender Equality). UNICEF has been pushing and working with many aid organizations to get more children in refugee camps into school, as it sees education as the best hope to help these children, “heal mentally and gain the necessary education and skills to build a better life for themselves and their families.” (Kubwalo). However, in the Za’atari, Jordan camp, now the second largest refugee camp in the world, 76% of the girls between 6 and 18 do not attend school even though it is accessible to them. (Schmidt). Among the factors that contribute to such low numbers of refugee children school attendance in Za’atari was the lack of appropriate toilets (Schmidt). In the Kakuma Camp in Kenya, fewer girls were enrolled at all levels of schooling than boys (El Jack 24). One Sudanese women who had lived in Kakuma, recalls that attending school was difficult because of the culture and traditions surrounding women. Even for the girls that woke up at 4 to do their household duties so that they might attend school still missed several days a month due to their periods because of the “poor hygiene in the camps” (El Jack 24). Girls all over the world miss school due to their periods, and that included girls in refugee camps. With the proper MHM materials provided these girls could earn back those days lost each month and help break the cycle of poverty and inequality.
Most refugee aid organizations, such as the ones mentioned previously, acknowledge the need to provide hygiene materials for both health and psychosocial reasons, however none of them have clear programs set in place to provide the materials and education. According to the UNHCR Global Appeal 2016-2017-Needs and Funding Requirements, 52% of women in refugee camps in 2015 did not receive sanitary materials due to the funding shortfalls. Disposable sanitary pads are expensive, and a great deal of money already goes to more necessary materials such as food, shelter and medical services. Therefore, a more economical solution is necessary in order to provide proper MHM materials, as well as MHM education.
The solution, is to have refugee aid organizations partner with women health organizations that already have an economical and effective solution. Pads4Grils, WINGS and Days for Girls are the only programs to date that are attacking the MHM issue head on, by providing girls across the globe with reusable sanitary materials. Most notably is the Days for Girls* non-profit organization which also provides MHM education and hires women who directly benefit from the program to be Days for Girls ambassadors. This global organization has been providing feminine hygiene kits, which includes absorbent reusable pads, moister barrier shields, Ziploc freezer bags (to transport soiled items), a washcloth, soap and panties, to girls in 80 countries as of 2014 (Annual Report). The kits cost $10, do not require much water to wash due to the tri fold design of the pads, dry easily, and last 3 years (“What’s in a Days for Girls Kit”). The giant work force behind the creation of the reusable pads are volunteers across the globe. Chapters and teams can be found on every continent; there are 184 alone in the United States (“DFG in the USA”). The chapters and teams sew, raise awareness and funds, and facilitate the transport of kits to areas in need. With so much experience with MHM, Days for Girls has been able to impact the lives of over 200,000 girls all over the world (“Annual Report”). The organization has only worked with the Adjumani Refugee Camps in Northern Uganda (Spelman), and by working in more refugee camps Days for Girls would be meeting their goal of, “ready feasible access to quality sustainable hygiene & health education [for every girl] by 2022” (“Our Mission”).
National aid organizations need to partner with established women health organizations, or create programs, to provide proper MHM materials and education to women in refugee camps. No longer can female menstruation remain the invisible issue if gender equality is to be met, in not only refugee camps, but across the globe. The day that every girl has access to proper MHM education and materials will be the day that every girl has access to education, it will be the day that the poverty cycle can began to end, it will be the day that more girls stop being forced into marriage, it will the day that one less vulnerability to be exploited exists for women. Why is it the catalyst? Because it will require acknowledgement from individuals across the globe of the most sensitive and taboo topic related to gender inequality. After the world is comfortable talking about menstruation, they will finally able to respect the female body for what it is and in turn respect every female for their inherent value.
*I am not a Days for Girls employee or ambassador, simply a concerned human being that thinks this program is incredible in addressing the menstrual hygiene management needs of girls across the globe.
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