Gender inequalities and women's health in South Sudan
Aishwarya reveals the outcomes of a research study conducted in South Sudan, shedding light on the humanitarian response programme concerning COVID-19 and the floods, and their impact on women.
Content warning: this article mentions gender and sexual based violence
South Sudan is in a vulnerable position, as it has a low capacity to cope with the global COVID-19 pandemic. The pandemic, in combination with existent poverty, high illiteracy rates, and an ineffective public healthcare system, has resulted in a battle in South Sudan for its people. Moreover, heavy rain, floods, waterlogging, and displacement have impacted rural communities in remote provinces in the Jonglei state. Floods have also caused shelter and water, sanitation, and hygiene (WASH) challenges. These challenges are a key public health issue within international development, as they are part of the first two targets of Sustainable Development Goal 6 by the United Nations General Assembly in the year 2015.
While the world is battling with the deadly virus, people in South Sudan are grappling with floods and heavy rain. “We are more worried about lack of food than we are worried about COVID-19,” said a respondent from our project titled ‘Process Learning of Christian Aid’s DEC COVID-19 Appeal in South Sudan’. This article discusses our research, which sheds light on the humanitarian response programme to both COVID-19 and floods, and explores the response in the context of women’s needs specifically. The study aims to understand the role of local communities and marginalised groups in Christian Aid’s Integrated COVID-19 Response Programme. Additionally, it offers recommendations for long-term recovery actions. The research was conducted through in-depth interviews and focus group discussions, along with household surveys in two provinces in Jonglei state, Fangak and Ayod.
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“While the world is battling with the deadly virus, people in South Sudan are grappling with floods and heavy rain.”
During these surveys, we were exposed to different risks that impact the lives of women in their communities, including patriarchal norms, lack of menstrual hygiene products, and the collapse of WASH facilities. These examples illustrate that the humanitarian response needs to take gender dynamics into consideration in order to implement equitable and effective programmes.
Gender
Food is crucial to communities, yet the process and responsibility to obtain it is dictated by patriarchal norms. Women in these communities, known as Neur, are imposed with the responsibility of bringing food to the plate under any circumstance. While the entire community is submerged under water due to floods and waterlogging, food accumulation becomes a tough task for everyone—not just women. Men expect women to look after “the food aspect” because according to them, they are usually “far away from home” to “earn money” or to let the cattle graze. Women tend to pick water lilies, weeds, and water grass from the swamps, and convert them into flour by drying and grounding, providing food for their families. They are also responsible for catching fish from the flood water, which are boiled or made into stews. Unlike men, who tend to have equipment for farming and cultivation, women have nothing of the sort and usually use what they have available, such as their bare hands and their clothes. According to female respondents, they use their frock or clothes to catch fish while squatting in the swamps.
The health outcomes observed from these practices include skin infections, vaginal infection, and skin rashes—attributable to the unhygienic flood waters in which they sit for prolonged hours to hunt food. In our household survey, 95% of the total respondents were female. While interviewing them, it was evident that there are gaps in community participation and gender inclusivity.
In a further workshop that we conducted, participants shared that women in this community have no rights over their own sexual reproductive health, as they could not decide who they marry, or when they get pregnant. There have also been instances where a man rapes a woman and she is forced to marry the perpetrator. Patriarchal attitudes along with the flooding has led to destructive impact on the sexual and reproductive health of females in these communities.
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“Patriarchal attitudes along with the flooding has led to destructive impact on the sexual and reproductive health of females in these communities.”
Menstrual Hygiene
Menstrual hygiene emerges as a growing need—the survey shows that 60.1% of the female respondents do not use any materials for maintaining menstrual hygiene, while 17.6% use old clothes or rags as a substitute for sanitary pads. During interviews with several women in the community, the participants mentioned that they “let it flow” or simply “avoid going near men”, as they either don’t have access to menstrual pads or have not been informed about menstrual hygiene products.
“We do not have sanitary towels, most women here don’t even know what that is,” said a female member during a focus group discussion. In the survey, 41.4% of respondents viewed “talks on menstrual hygiene” as something that should not be publicly discussed. However, 23.2% suggested that if menstrual hygiene awareness was provided to their spouses as well, it could help them to handle menstrual hygiene “culturally and respectfully” within their family circles.
In the context of these taboos about public displays of menstrual hygiene, 40.8% of respondents stated that when disposing of menstrual hygiene products they “hide them away” from men instead of disposing of them in a hygienic manner. 25.7% bury them, while 12.8% “wash them for re-use” and 1.9% throw them away in open spaces. As such, sanitary products are seen thrown away in the flood waters.
While diving deeper into the challenges faced by women in the community on a day to day basis, it’s evident that factors like floods, rains, and waterlogging can’t be the only reason for these problems. Lack of community participation programmes by both the government or humanitarian agencies, and the absence of counselling and awareness programmes all contribute to a lack of knowledge. Female respondents stated that the presence of these might be useful to better manage their menstrual hygiene needs.
Collapse of WASH
The floodings have changed the dynamics of hygiene practices. Several respondents claimed that people in the community drink the same (flood) water that they defecate and bath in. Every situation here is connected to one another: lack of toilets leads to open defecation and lack of dry land due to floods leads to defecation in the flood waters. According to our survey, only 6% had access to a latrine. However, existing toilet facilities do not work, so most people continue to defecate in the open, usually in flood waters.
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In the absence of clean water for drinking and domestic use, people had no option but to use the logged water in front of their houses. There are limited practices of boiling or filtering water, so in most cases they consume or use it directly. This contributed to several water-borne diseases among people along with skin infections and Urinary Tract Infection (UTIs). In case of UTIs, people manage by “praying to God” for protection as they either shy away from seeking help or simply lack medical assistance.
COVID-19
Christian Aid in partnership with Africa Development Aid (ADA), a local Non-Governmental Organisation (NGO), implemented the DEC Coronavirus Appeal from August 2020 to January 2021 in these two counties. They aimed to increase knowledge amongst communities and healthcare providers on protection from COVID-19. Moreover, they focussed on improving the negative economic impact of COVID-19 on household food security and livelihoods.
To advance preventive actions against the virus, the project partners established 100 handwashing stations in Fangak. However, during our household survey, it was found that 93.1% did not have access to hand washing stations. Instead, 36% of people used ash or mud and 50.3% flood water to wash their hands, while only 13.7% used soap to prevent COVID-19 infection. During the interviews, respondents explained that soap was either stolen or out of stock. Moreover, in many cases, these hand washing stations were located far away from people’s homes.
Like one of the key informants said in an interview, “Flooding, hunger, health care, clean drinking water, and toilet facilities are the highest gap and urgently need a response”. Indeed, our findings suggest that the humanitarian response programmes should address these multiple risks and needs at the community level, including shelter, water and sanitation, menstrual health, gender-based violence, and education. Lastly, there are gender dynamics and traditional roles for women and men which should be considered when making equitable and responsive future programmes. Humanitarian response programmes and governments must work together to equitably and effectively improve facilities in these communities through conscientious attention to women’s needs.
“There are gender dynamics and traditional roles for women and men which should be considered when making equitable and responsive future programmes.”
The evaluation work discussed in this article was conducted by Environment Technology Community Health (ETCH) Research Consultancy, India. Special thanks to our partners in this project: Christian Aid (UK), Africa Development Aid (ADA), and everyone involved on and off field, amid floods and pandemic.
How the "menopause is natural” narrative is a damaging one
Aishwarya explains that discussing menopause as a natural phenomenon perpetuates social and health inequities, leaving women to push through their symptoms alone without practical and effective health advice.
If you Google menopause, a long list of symptoms appears. There may be a mention of how menopause symptoms are unique from person to person and advice not to take the list of symptoms at face value. But that part may be skipped over, leading straight into a paragraph on hysterectomies and hormone replacement therapy (HRT). This paints menopause as a well-structured process with simple solutions. It was only when I began to search for research papers on menopause in India that I uncovered a glaring problem: in conversations about menopause, authentic experiences had been left out completely.
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“In conversations about menopause, authentic experiences had been left out completely.”
Menopause is the one-year anniversary of a person’s last period. Since a person is born with a finite number of eggs in their ovaries, at a certain age, usually between 35 and 55, the number of eggs reaches below a threshold. Oestrogen—the hormone responsible for retaining and maintaining this constant—begins to fluctuate from its cyclical nature. As oestrogen governs more functions than just the menstrual cycle, decreasing hormone levels also result in a spectrum of symptoms throughout the body. For example, oestrogen plays a key role in controlling body temperature, and a low oestrogen level can cause a sudden spike in body temperature known as a ‘hot flash’ or ‘hot flush’—a common symptom of menopause.
I decided to conduct my postgraduate research on menopause experiences of cis-women in India through qualitative interviews. My research asked: if women were reporting difficulty during their perimenopause (the 5–15 years of physiological changes leading up to menopause), were their negative experiences a result of not making use of the available medical facilities? Since COVID-19 had limited my sample to middle-class women with access to Zoom, my participants were all literate and had easy access to hospitals and gynaecologists. But by the end of the first interview, it was clear that I had a lot to learn. My ignorance stemmed from a combination of my own privilege, and my education: studying science had distanced me from social issues and structures. By the end of my 30th interview, I had uncovered just how entwined social and health inequities are.
One of the most common phrases I heard was “it’s natural”. While menopause is indeed a natural phenomenon—after all, periods do eventually stop—calling menopause ‘natural’ seems to be doing more harm than good. If women are not accessing health infrastructure, and if health infrastructure is barely covering (or over-medicalising) the menopause, a deep dive into the ‘natural’ narrative may uncover some truths about where these health gaps lie. In the words of the women themselves, here is why the concept of menopause as ‘natural’ is both born from social inequities, and why using it perpetuates health inequities.
Calling it natural is a coping mechanism caused by lack of support
“Natural actually sounds good but I wish it was not traumatic. Not painful. I wish it was like, once you decide you don’t want to have kids you switch it off and everything stops. That would be more natural for me.”
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A menopausal support system requires two systems, each depending on the other to be effective: the social system and the medical system. While good gynaecologists may be available, most menopause symptoms do not have quick fixes. Dr Shaibya Saldanha, a gynaecologist in Bangalore, India, stressed the fact that menopause does not need to be a medical phenomenon. At the same time, she made clear that a natural process does not mean one without dietary and lifestyle interventions. For example, during perimenopause, sleep should increase while the body adapts to hormonal changes. However, “Women normally run on six hours of sleep … .They close the house down in the kitchen and feed every single person who eats at different times. And then they go to sleep and normally they would get up at 5:30–6:00 and start the next day.”
Solutions may appear feasible—such as sleeping for longer or shifting household duties to another family member—but support is often lacking. In a culture where gender roles are so deeply ingrained, social inequities play a role in menopause experiences. For example, the COVID-19 pandemic added to the workload of urban women, and this stress alone could have increased hot flashes and emotional fluctuations. Further, stigma surrounding menstruation continues into menopause. In some interviews, the women were unable to explain their menopause symptoms to their husbands because they had been discouraged from talking about their reproductive health during puberty.
This combination of shame and the lack of support at home leads women to use the word “natural” as a way of sweeping their health under the rug. If their health is not taken seriously then it must be unimportant, and most bodily processes that aren’t given attention are natural ones. Thus, menopause and its accompanying symptoms, no matter how harrowing, must be natural too.
An ayurvedic doctor that I spoke to explained how she bridged this gap. When a menopausal woman enters her clinic, this doctor ensures that either the husband or another family member is present during the consultation.
“Everyone takes doctors seriously and our word weighs. That extra step in counselling makes a big difference in fighting stigma.”
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Natural processes are common, and therefore you will manage
“Once [women] speak to their family they are ridiculed. Women of our generation are convinced, and it is very unfortunate, by women themselves. By women of the previous generation. They themselves say, ‘Oh you take this all so seriously, it’s very natural. You make a big deal out of nothing.’ Mind you this is not said by men. This is said by previous generation women. They are the ones who find it ridiculous.”
Two generations ago, treatment for menopause did not exist, nor did women have access to healthcare facilities. Tasked with running a household, women put their own health last. Along with the stigma surrounding menstruation, women had no choice but to manage their menopause alone. One of the most important long-term effects of the change in oestrogen level is a decrease of calcium uptake in the body. People going through menopause are encouraged to increase or supplement their dietary calcium intake so that postmenopausal concerns such as osteoporosis and arthritis are prevented. Unfortunately, rather than appreciating the availability of medical advancements for their daughters, women often look down upon other women who seek medical assistance. Silently suffering is seen as a display of strength: “We never used to complain about our cramps,” becomes “We never went to hospitals”. The prevalence of osteoporosis and arthritis in this generation shows just how damaging social inequities can be for health outcomes.
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Women’s health doesn’t warrant relevant medical attention
“We have a doctor but we don’t go much to the gynaecologist because it [menopause] is a natural process.”
Both postmenopausal women whom I spoke with regretted not having a check-up at the gynaecologist’s office. Yes, menopause is not a disease and nor is it a disorder, but, at the very least, a blood test to ensure that calcium and vitamin levels are normal is a must.
But the narrative around women’s reproductive health has always been ‘to manage’. Menstrual cramps in the middle of a class? Keep your head down and power through. A miscarriage? You’re shooed out the hospital door and expected to deal with the trauma on your own. Polycystic Ovary Syndrome? Despite it becoming an increasingly common condition, there is little progress in medical care provision. You’re handed a set of birth control pills and told to manage the side effects. Similarly, self-managing your menopause transition is the expectation. In fact, a woman who did seek medical help was dismissed by her gynaecologist who said, "Menopause is a part of life that everyone manages through.”
When it comes to menopause, unless your symptoms can be treated by medical intervention, there’s no space for a person going through menopause to seek guidance or support. “You have to stop everyone from removing your uterus,” was a common sentiment heard during my interviews with women. Instead of broadening the kind of support a medical environment can offer, menopause is medicalised and the fear of having unnecessary tests or operations prevent women from going to hospitals. Dr Saldanha told me frankly that there are only a few gynaecologists that sit menopausal women down and explain the practical lifestyle changes they can make to ease their symptoms. She had completed a one-year counselling course specifically so that she was better equipped to help the menopausal women who walked into her clinic. However, this kind of menopause counselling does not commonly feature in medical school curriculums.
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The lack of menopause education in medical schools because it is a natural process
“And I think that’s the nuances of medicine that is not taught to any of us as doctors. Beyond health; the needs of people. What about preventive health, what about a step beyond that?”
Menopause counselling sounds like a tall order, considering how menopause itself is barely covered in the MBBS (Bachelor of Medicine and Bachelor of Surgery). Five women interviewed were medical professionals and they were all disappointed by the lack of menopause training. Public health tends to focus on the prevention of disorders, diseases, and ailments. Although menopause should not be looked at through any single lens, public health education and health promotion should encompass menopause. When discussed, menopause is also primarily and problematically grouped under ageing concerns. The average age of menopause in my study was 47, and women reported feeling disconnected with the concept of menopause being a sign of old age. Generations ago, menopause may have come towards the end of life, but lifespans are longer than they have ever been.
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“I don’t want to have one foot in the grave. I am working, I actually started a new academic program just this month. I don’t think of myself [as at] that age… It doesn’t have to be a natural part of the end in life. It’s going on while life is also going on.”
Rather than finding an answer to where and how menopause should be taught, it’s skipped over altogether, with medical colleges teaching a slide or two at most. This has led to many medical professionals not knowing what menopause symptoms are at all. Since the onset of perimenopause is unpredictable, women often visit a general practitioner first for their menopause symptoms. Unfortunately, many women in my study consulted multiple doctors before the word ‘menopause’ was even brought up.
How do we remove these systemic health and social inequities?
One of the most important things that I learned through these conversations is that ‘natural’ does not necessarily mean a ‘good’ thing. Although the menstrual cycle is a natural process, its stigmatisation turns it into something negative. On the other hand, the perception that everything “God-given” or “natural” has to be good prevents women from seeking help when a natural process doesn’t feel good.
Public health systems need to take the initiative to spread menopause awareness, and doing so should involve those who will not experience menopause too: de-stigmatisation begins with open conversations. It is thus imperative for menopause counselling to be a part of every gynaecologist’s training. Considering that menopause can intensify mood swings and lead to depression, “removing the uterus” should not be the only intervention that gynaecologists are equipped to provide. Validation is an important and missing component. All of the women who had negative menopause experiences thanked me for simply giving them a space to share what they had endured. Because of health inequities, doctors did not give them a safe space or the time of day to allow them to share their trauma; and because of social inequities, they were unable to openly discuss the negative aspects of menopause at home. A combination of more research and counselling would help to validate that what is natural is not always good. More often than not, women understand that they will have to push through their symptoms; they also want proof that what they’re going through is indeed natural, and that it is okay to not enjoy it.
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Menopause is something that cannot and should not be generalised for all. If the person makes the choice to seek medical support, infrastructure and solutions should be available. If the person decides to go through the menopause symptoms without any medical intervention, social systems should be available to support them. Most importantly, strengthening both social and health structures will allow people going through menopause to be able to rely on both. With neither system currently making space for menopause, the word ‘natural’ has become synonymous with ‘isolated’. Women deserve more.
“Menopause is something that cannot and should not be generalised for all.”
Tiles
Emily reflects on the experience of working as a healthcare professional serving rural communities. This poem draws on the inspiration from colour and its contrast to the surrounding setting.
During my undergraduate degree, I completed a semester abroad in South India, where I took Public Health courses through a local university. As part of the programme we went to field visits once a week in the local community. This poem is about one of our visits to a tile factory. I was struck by the state of the factory: a dilapidated building strewn about with broken tiles, bricks, and the like. Dimly lit and dusty, the air was loud with the cranking of machines and the slapping of clay against oiled metal. In the midst of this relative chaos, women decorated by brightly coloured kurtas were working to make bricks on the lower level of the building. I was struck immediately by the contrast between the bright fabric of their clothes, and the dust and dinge that whirled around them. The image of these women, appearing in such stark contrast to their surroundings has stayed with me and from it this poem materialised.
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A girl walks the line,
Skirt drawn
Hands caked with clay
A grey streak marks her a laborer.
Sweat glistens in the sunlight that has snuck through the thick air
Her arms carry what will one day be a home
While her body,
covered by the dust of another man's future,
Is already home to her own.