The Association of Public Health Specialists (Halk Sağlığı Uzmanları Derneği – HASUDER) established a “Women and Reproductive Health Services in Disasters” unit in Hatay after the February 6 earthquake. Prof. Dr. Türkan Günay, the coordinator of the project, talked about the contraceptive methods they procured to take to the region, how they work and the latest situation in Hatay in the field of women’s health, including abortion. Dr. Günay also talked about how tent cities should be organized against sexual violence, which is expected to increase, and shared the following via Zoom.

When, why and under what circumstances did you go to Hatay from İzmir?

On the morning of March 14th, I first set off for Adana because as HASUDER, we had sent all the purchases of our project to establish and maintain a Women and Reproductive Health Services Unit in Disasters to the Medical Chamber in Adana. We also had locally sourced materials, and together with Nurettin Özdener, our public health specialist in Adana, who supported this project, we completed everything and set off for Hatay in the evening with a pickup truck and a passenger car sent by Hatay Metropolitan Municipality. In the Lions Disaster Village tent city established by Mersin Metropolitan Municipality in the Expo area, as you saw we had two containers that Prof. Dr. Nazan Savaş had provided and placed before; when we arrived in the evening, it was raining and we started by loading the materials into these containers in case they could be damaged.

This is how I left, but it was in 2017 that HASUDER was introduced to the practices of MISP (The Minimum Initial Service Package for Sexual and Reproductive Health in Disasters and Emergencies). In 2017, HASUDER organized a training of trainers with UNPFA (United Nations Population Fund) in İzmir. Public health, midwifery, nursing faculty lecturers and research assistants from 17 different universities who responded positively to the open call were informed about the content of MISP and the steps of the implementation for five days. Everyone was asked to integrate this training, which includes the steps we are currently trying to implement in the region, into their own training. Then, in 2018, there were two three-day practitioner trainings in İzmir and Aydın. Here, what to pay attention to in the content of the package and how to coordinate was explained. We conducted online trainings during the Covid period and these trainings have been ongoing since 2020. Final year medical students from different universities now have to receive this training. For example, 9 Eylül University Public Health has integrated this into its own training and about 50 students complete this training every two months; so do Aydın Adnan Menderes University and Hatay Mustafa Kemal University. In other words, there was a team interested in MISP within the public health departments since 2017, and when we heard from the Sexual and Reproductive Health and Reproductive Health Rights (Cinsel Sağlık ve Üreme Sağlığı Hakları – CİSÜ) Platform that IPPF (International Planned Parenthood Foundation) was looking for partners to implement MISP in disasters, we had meetings with IPPF and quickly wrote a project. When the project was accepted, we quickly planned our material purchases and how we would set up this unit and went to the region on March 14.

What are the MISP steps you are currently implementing in the region and what are the materials you say you have purchased?

The project has six main topics: 1- Make coordination mechanisms work, 2- Prevent sexual violence, establish a mechanism against sexual violence, 3- Prevent maternal and newborn deaths, 4- Prevent unwanted pregnancies, 5- Take measures against the spread of sexually transmitted diseases, 6- Ensure that reproductive health services are integrated into basic health services. What have we done? First of all, we need to have contraceptives to prevent unwanted pregnancies, so we bought them: Birth control pills, condoms, morning-after pills, intrauterine device (IUD), examination table for the application of the IUD, and all the materials that will ensure sterilization and application there. We bought pregnancy tests. Again, during this period, women have difficulties in accessing pads and underwear, so we bought them. With the project, we employed a physician and two nurses, and we prioritized them to be health workers from the earthquake zone. Currently, two of our nurses are also earthquake survivors. Our physician had also started, but she/he left because she/he thought it was difficult for someone who experienced the earthquake to continue. I worked as a physician while I was there, and another friend of ours has been providing services for the last week. The project also has intervention steps and one of them is to ensure coordination. Normally it is the Ministry of Health that should do this, but we tried to provide some of that coordination by connecting with all the institutions there, so that we could communicate with the obstetrics and gynecology department and professors at the university to get support when needed.

Which university are you talking about? Which hospitals around Hatay currently offer women’s health services?

We contacted Mustafa Kemal University Hospital, its obstetrics and gynecology faculty members and assistants. Two of the professors involved in the project are from this university, Prof. Dr. Nazan Savaş and Prof. Dr. Tacettin İnandı, who are also our field coordinators. We also visited other health institutions in the region to see where else we could get services from, and we reached an agreement that the obstetrics department at the Private Mozaik Hospital could support us in case of need. There is also a field hospital established by the Ministry of Health, but when I was there, the obstetrician had arrived but had not started yet.

When you started working in the tent city, what were the most common complaints women came to you with? How did they receive you in person?

I couldn’t observe much because I tried to establish the clinic in the less than two weeks I was there. But after it was first established, when we were giving information, women came with vaginal discharge and bleeding disorder. Of course, we started to share contraceptive methods with them, but when they came with discharge, our treatment attracted attention because it was a very simple and quick treatment.

If you don’t mind, could you share the name of the medicine? Maybe someone from the region will read it and benefit from it.

With vaginal discharge, we think of two or three diseases: One is bacterial vaginosis and the other is trichomoniasis, which is a bit greener and has a malodor. In both cases, metronidazole works, when you give it a single dose of two grams, it affects the discharge. Fungi is also a common cause of discharge. In candida or fungus, the discharge is like a milk cut, it is very itchy, then we gave fungicide. When the woman gives permission, we can make a diagnosis by examining her, and when she does not give permission, we can make a diagnosis by asking how the color, characteristic and smell of the discharge is with the syndromic approach recommended by the World Health Organization for diagnosis, and I was proceeding in this way.

What are the reasons for these to be experienced intensively?

Pads are not changed often enough and underwear can remain wet. Fungus develops especially in humid environments. There are also a few traditional practices that women pass on to each other incorrectly: First, women wipe from back to front when urinating, which brings germs from the anus to the front and causes urinary tract infections. After using the toilet, cleaning should be done from front to back and dry thoroughly. This is still unknown. Secondly, the chamber should not be washed by inserting the finger into the chamber/vagina. But in our country, there is a habit of washing the inside of the chamber after menstruation or intercourse. Normally, two of the factors that cause this discharge are present in the vaginal contents of the woman, but they do not cause disease. The pH of the secretion inside the vagina is acidic and this environment both kills the microbes coming from outside and prevents the microbes in its structure from causing disease. When you disrupt the flora inside the vagina, its pH by washing inside the chamber, it turns from acidic to basic. When you make it basic, microorganisms that do not cause disease suddenly start to increase and become in a position to cause discharge. Therefore, we explained that the inside of the chamber should not be washed and we gave medication. After these two corrections, I received feedback that “my discharge has been cured” on my way back.

Since we have witnessed distributions that are generally not enough for the earthquake-affected population, I was curious about this: In what quantities have you purchased methods such as the morning-after pill or IUDs? Since these are things that need to be given under the supervision of health professionals, how do you ensure that they reach women? And can women from other tent areas or villages knock on your door?

Let me share the exact number; apart from some of the materials I mentioned, we bought 400 birth control pills, 100 morning-after pills, 6.000 condoms, 200 IUDs, 1000 pregnancy tests, 100 pads in packs of 20, 500 underwear. We planned to give the underwear and pads to the women we serve in our unit. We have prepared a bag with brochures on contraceptive methods and mechanisms to combat sexual violence, which we give to women along with pads and underwear. We also give the methods to those who come to pick them up or receive counseling from us. While I was there, women from nearby villages who were aware of our existence also came.

There is also something like this: After the earthquake, there were no birth control methods anywhere, especially birth control pills and IUDs; IUDs were not being worn anywhere. The fact that this center brought these materials enabled many institutions to use it as a logistics center. We gave birth control pills, pregnancy tests, morning-after pills and condoms to the TTB (Türk Tabipleri Birliği – Turkish Medical Association). We also gave materials to the District Health Directorate, for example, birth control pills; they had pregnancy tests and condoms. We also gave materials to groups of doctors and women’s solidarity networks that visited the regions. NGOs and the municipality provided support to other locations like Samandağ by getting the materials from us. Except for the IUD, of course. For the IUD, we currently do not have a vehicle that will allow us freedom of movement. We are talking about whether this system can be prepared in the back of a minivan, but this requires bigger budgets. We have started our service, the month of Ramadan has started, and I think the demand for wearing the IUD will increase after the end of Ramadan.

Excuse me, you said you gave birth control pills to the District Health Department, right? Did you also provide the state’s supply?

Yes, we suggested and gave it to them so that they would have material in their hands if they encountered such a thing in tent cities. In order to give it to women between the ages of 15-49, including pregnant women, when they have such a request while monitoring them in tent cities. Because women who normally use birth control pills cannot access them now. We had already met with the Directorate of Health beforehand and got their approval. HASUDER had also visited the Ministry of Health.

What I am questioning is not whether they are aware of it or not, but the fact that you are supplying materials to the Ministry of Health units when it should be the other way around.

But, as you know, women could not access contraceptive methods within the system also before that. In fact, I even refer to this as violence against women. After 2012, what was in the law did not happen in practice due to the practice of gradually increasing fertility. We have always said during the pandemic, family physicians did not have contraceptive methods at their disposal. Condoms were bought and sent immediately after the earthquake, but the state had already withdrawn them from the primary healthcare system.

As a result, according to UNFPA’s 2022 report on reproductive health in Turkey, the most commonly used contraceptive methods are condom use and pull-out, where men are the decision-makers. In fact, the IUD, contraceptive pill and morning-after pill that you provide open up this space for women. But even in terms of condoms, the need for condoms after the earthquake in Hatay alone is estimated to be around 350 thousand. Is the delivery you mentioned enough to meet such a need?

You are buying within the limits of the funds sent to you from abroad, but there will be more to come. Currently, UNFPA has activated the kits that will come in emergencies and on Monday (March 27, 2023), those kits were delivered to the Directorate of Health. We received the continuation of the kits that UNFPA sent to our unit. After that, there will be a flow and it will come as needed because the need is calculated according to the population. We did not have such an option in our purchases.

What is included in the kits UNFPA sent to the region?

Materials defined in the minimum initial service package.

When I was working before the interview, I saw that UNFPA’s kits included abortion kits, post-rape treatment kits, forensic kits, etc. Are these kits among the ones that came?

According to the information I received from UNFPA, they have all arrived. The list they shared includes kits for clean delivery, managing complications of miscarriage, vacuum extraction assisted delivery, treatment of cervical and vaginal tears, male condoms, post-rape treatment, treatment of sexually transmitted infections, clinical delivery support. UNFPA made the urgent call and brought the kits needed for minimum first aid.

What, for example, is in the rape kit?

The post-rape kit must absolutely contain the morning-after pill and medication for HIV. Apart from that, there are all tools to determine the findings of rape in the raped person and to collect evidence.

Are we talking about tools like cotton swabs for taking semen samples?

Yes, yes.

It is suspicious whether the ministry will deliver it, but what are in the abortion kits?

Up to 10 weeks of gestation, manual vacuum aspiration is available to terminate pregnancies.

Is it possible to have an abortion in the region now?

There is only Private Mozaik Hospital. I specifically tried to establish a mechanism where we can terminate an unwanted pregnancy if we detect one, but there is no such place in the public sector. The private hospital used to work without charging for a month, but now I heard that it has started charging. If people have an abortion, how will they pay for it? They cannot pay for it themselves, there must be some other source.

Getting an IUD inserted was also a procedure that cost close to 1500 liras if it had not changed. It is very difficult to spend this money to terminate or prevent pregnancy in such a period when there is no water or food.

The state has an obligation to do this. We need to remind them of this all the time. According to Law 2827, if couples want to terminate an unwanted pregnancy, the state is obliged to provide this service. No one has to pay for it out of their pocket.

Apart from the socioeconomic limitation brought about by this situation, what about other dynamics, such as LGBTI+s’ and migrant women’s access to reproductive and sexual health services?

The situation of all groups we call disadvantaged is troubled in the earthquake zone. LGBTI+s already had concerns while receiving services in the previous situation and could not use public institutions much, but now they are really vulnerable. Services are mostly for pregnant women, obviously to prevent more risky things. There are associations for LGBTI+ rights on the CİSÜ platform and they said that they contacted those who use medication for HIV in the first phase of the earthquake and delivered the medication, but I cannot say anything specific to Hatay. There should be HIV tests for early diagnosis and volunteer centers to implement them. Regarding migrants, Hatay is in a better situation because migrant health centers are more established. There are also refugees in our tent city and our nurse friend in our clinic speaks Arabic. The fact that Syrians are not a new phenomenon facilitated the process in the region, maybe that is why I did not hear anything specific for migrants.

In such an environment, where we are talking about a health system consisting of three hospitals, one private and one field hospital, do you have any estimates of the number of complications, miscarriages or deaths in childbirth in the near future?

Let me share the calculation I made on MISP Calculator on February 16th: For 15.160.583 people in the earthquake zone, the number of pregnancies that would result in miscarriage or unhealthy abortion, which means abortion without health personnel, is 2.921 in the first month and 8.764 in three months. There is no information on the number of maternal deaths due to unintended pregnancy, but in the international maternal mortality study conducted in 2005, the share of unintended pregnancy in maternal deaths was shared as 2 percent. Maybe it can be considered from there.

With what data does the algorithm of this calculator proposed for all disasters work?

The Inter-agency Working Group on Reproductive Health in Crises offers this service. You enter the name of the country and region or city into their calculations, and the calculation is based on rates previously shared with international bodies, such as maternal mortality rates at birth. According to the figures for the earthquake zone where 15 million people were affected, the number of fertile women in this population is 3.941.752, the number of sexually active men is 3 million, 606 thousand of them use condoms, and the number of modern contraceptive users is about 2 million. When we say the number of live births in the next 12 months, we see that the current number of pregnant women is over 200.000. These numbers show us that we need to include not only shelter and infectious diseases but also reproductive health in our planning. In addition, while 78.835 cases of sexual violence are expected, an estimated 2921 births will have to be performed by caesarean section in 3 months.

And there is still no caesarean section service in the region, right? 

Not in public institutions.

One of the reasons why we are talking about all this is sexuality in times of disaster. What kind of potential are we talking about in this period, is it increasing when it was expected to decrease?

What we have seen in previous earthquakes is that loss increases the desire for pregnancy. Psychiatrists and psychologists can explain this better, but I can say that life does not stop and sexuality continues. That’s why the organization of the tents is very important. People’s privacy needs to be taken care of. These are normal in the course of life. It is not an increase, but it results in pregnancy because there are no precautions taken during the normal flow of life.

As far as I understand, it is unclear from the research whether pregnancy is a desire or a consequence of the lack of preventive methods, but in other disasters, for example in Nicaragua after the 1998 hurricane, there was a 200 percent increase in pregnancies within two years in the damaged areas compared to the rest of the areas. How should tent cities be organized both to provide this privacy and to prevent sexual violence?

There is theoretical information about the establishment of tent cities, such as 8 meters between tents, 2 meters from the road. If these were implemented, I would say the others, but in all the tent cities we observe at the moment, the tents are right next to each other, especially there is no structure to provide that privacy. But even if the tents are set up as we want, one of the things we need to do to prevent sexual violence is to ensure that there is good lighting, that the tents of elderly or young women living alone are close to administrative units, because when you leave them in the back, the possibility of being abused increases. Having female staff both in tent cities and in aid distributions is another measure to prevent violence. In addition, all men’s, women’s and unisex toilets and showers should not be close to each other, but in separate places and lockable from the inside.

Why can the toilet be a potential site of sexual violence?

Because women can be detained inside the toilet. Therefore, showers and toilets should be lockable from the inside. Also, if the toilet is in very remote areas, it can happen on the road, but there was no such distance in the tent cities we saw. When you put the toilets in separate places, it is much easier to see a man hanging around in front of the women’s toilets. A man would not dare to do that in such an environment. But if the toilets are next to each other, the risk increases as people will go to these places side by side. Also, society needs to be aware of this and the mechanisms in place.

What kind of mechanisms were there against sexual violence in the tent city where you stayed?

Lighting was good at different hours, but the biggest problem was that the toilets were on one side of the tent city and it was not possible for women to get there at night on their own from one end. Let’s not only think of sexual violence as rape, but also include the possibility of hunting or showing organs to disturb the woman, there was no situation that took these into consideration in the tightness between the tents. The middle tent between the three tents should have been removed, we told them that, but it was done that way and you can’t move people from their places, and there is an expectation of moving to a container. We gave information to the women about sexual violence, you know women wash clothes in the bathrooms, we told them in our casual conversations there that this is a possibility and if it happens you can come to us. They told me that they had already thought about it and when they had to come at night they came to the bathroom with their husbands. But what will the woman alone do? That is where the problem is.

In Mor Çatı’s regional monitoring report, there was a note that they heard from public officials in the tent areas that in the event of a possible case of sexual violence, “the necessary action will be taken”, but no one knew what the necessary action was. How was a possible case of violence monitored in the tent areas where you live or in the surrounding areas?

We could not discuss this with the tent administration, but there were psychologists from the Ministry of Family and Social Services there, I talked to them. “We hadn’t thought of that,” they said. I said, “Make sure you question this in your conversations.” Actually, it is easy to operate the system once you are aware of it, the aim is to create that environment to be aware of it. Because when something like this happens, women do not immediately report it, they hide it. Especially in a situation like this, they hide it separately. Otherwise, the thing to do is of course to activate protection mechanisms such as ŞÖNİM (Şiddet Önleme ve İzleme Merkezi – Violence Prevention and Monitoring Center), but where is ŞÖNİM there now? There is none. We raised this issue when we visited the bar association. We also told them that we have the morning-after pill and that it is necessary to take it within five days to terminate an unwanted pregnancy.

As far as I have observed, gender inequality is very obvious in the region. I have always seen women doing work. Food is served in tent cities, but they may not always want to eat the food served there, at least the kitchen should be organized in tent cities, and there should be an area where they can wash their dishes. There should be an area where they can do their laundry, there should be machines. In addition to the fact that it is difficult to have order in the tent, the burden of care on women has increased. The woman does everything. She takes the aids, she cooks, she takes care of the child, she tries to fix the man’s depression, she takes her mother to the toilet because the toilets are not designed for the elderly. The woman is not thinking about herself right now. She came to us because it was a cure for her discharge, but if we had not been there, she would not have gone to another tent camp or health institution because she had a discharge. She would have managed it by herself. The fact that the unit was there made her come there. Because she has more vital things ahead of her. There should be environments that will better operate psychosocial mechanisms and heal women. For example, when hairdressers came to our tent city, women sat together and socialized, but more space is needed. In the past, they used to have neighbors with whom they socialized, but now it is not their neighbor in the tent, but a fellow citizen with whom they share the same situation. It is difficult for her to share with her. Under these conditions, women are more alone and in a very difficult situation. It is very painful that everyone starts by saying, “I don’t want to sound like a complaint, but”. It already feels like a great gift to have survived, but after a while, the fact that some things are still not happening will turn into tensions and violence. Violence against women was already there, we should be ready for it to increase with the increasing violence.

For the original in Turkish / Yazının Türkçesi için

Translator: Gülcan Ergün

Proof-reader: Müge Karahan


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