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Promoting hygiene amongst earthquake survivors through innovative measures

© UNICEF/Pak/J Marroquin
7 year old Ashfaq, sings a poem on megaphone for children in Havelian.

By Julia Spry-Leverton

Right from the first days after the earthquake that rocked northern Pakistan on October 8 2005 the hygiene needs of people displaced from their homes have been a serious concern. UNICEF took the lead in providing support for Water and Environmental Sanitation in the hundreds of camps set up to house those who had left their devastated communities. Providing a clean water supply was top priority, closely followed by constructing latrines (to date 5500 have been installed by UNICEF working through partners.)

Now four months since the quake there are more than 136,000 people gathered in planned and spontaneous camps in Pakistan administered Kashmir and North West Frontier Province (NWFP). An ever-present fear in situations like this when people come rapidly together is that communicable disease will strike and swiftly spread to reach epidemic proportions, prompted by poor hygiene. Children are the most vulnerable at these times, and always the first to succumb to and die from illnesses such as cholera.

Conditions are difficult. Families of often up to 10 people are living in one tent, sharing communal cooking facilities and latrines. A sizeable percentage of these displaced populations are mountain villagers who have lived isolated lives, hardly ever exposed to crowded urban areas. Among the many changes they are experiencing is the need to use latrines, formerly not part of their cultural practice.

To safeguard the health of these large groups of people living in close proximity a key activity is putting in place hygiene promotion programmes to spread messages about adopting vital practices such as correct utilization of the latrines to keep them clean, handwashing with soap, and ensuring drinking water is safe.

Initially, posters and leaflets with the messages in Urdu language were rapidly developed and many thousands printed and distributed widely. Almost overnight, every water tank supplying the rapidly-expanding camps was fly-posted. Subsequently, these were replaced by simple bright graphics painted on to the tanks’ surface, demonstrating without words, for example, that food should not be touched with dirty hands.

To make sure that the programmes get general acceptance and “buy in” and benefit everyone to the maximum, UNICEF hygiene promoters are using participatory methods, consulting with the communities on how to achieve the desired behaviour changes. The promoters at no stage impose rules, since, as the UNICEF Emergency Manual clearly states, “Messages on the importance of hygiene will have no effect if they are not accepted by the affected community. It is extremely important that messages be discussed with vulnerable groups, especially women and children.”

© UNICEF/Pak/A Kulkarni
A camp resident pouring a bucket of cold water into the barrel inorder to get her share of hot water

Fauzia Minallah, a young artist and graphic designer from Islamabad has been at work in Havelian camp, Mansehra district NWFP, assisting in the design of one innovative hygiene promotion campaign drawing on interpersonal techniques. She explains how she uses her photographic skills, “I capture pictures of people demonstrating bad hygiene practices, for example cooking with unwashed hands or leaving the latrines without using the soap and water provided there. When we’re talking to communities we see how they empathize more if they are shown pictures with people they recognize.” 

Fauzia identifies a major challenge in the fact that so many people from various locations are now together in one place, saying, “These people arrived here from different areas - community feeling is not there any more. When we suggest they play their part in maintaining camp cleanliness they ask, “Why should I clean if she doesn’t?” This attitude is what we try to change by discussing all around the subject with small groups of women.”

Accompanied by hygiene promoter Saima Anwar from UNICEF partner agency Taraquee Foundation, Fauzia sits in a circle with a group of twenty women on the tarpaulined floor of a community tent and shows them some of her graphic images. One is of a small girl; although her eyes sparkle her face is covered in grime and the fingers she puts in her mouth are streaked with dirt. A young mother in the group, Sabina, speaks out clearly as she looks at the photograph she’s been handed, “The mother is responsible for her daughter’s personal hygiene. We all should know we are responsible for daily cleaning and washing.”

Another programme, one focusing specifically on children, is in place at nearby Jaba camp. The camp sprawls over some low hills, home to 2,990 people from Mansehra  and Balakot, the latter a town almost 100 per cent destroyed in the quake. In the bright winter sun boys and girls mill around Shana Hal, a public health assistant. She grabs a megaphone and calls out, persuading the children to sit down. “Its 11 o’clock now, time for poems” she says, and she asks the children to come up to her one by one.

Muhammad Ishfaq, 7, takes the megaphone and sings out the words of the well-known poem, Murgha. The children start clapping their hands in rhythm with his powerful voice. Hygiene questions come next, “Why is it necessary to wash hands?” calls out Shana.  Most of the children raise their hands and Shana points to Anita Bibi, a young girl who answers clearly, “So we can get rid of germs.” Then she mimes to show how hands should be thoroughly washed using soap.

“We take thirty minutes out of the school curriculum every day to work on this with the  children. Selecting some of them to do puppet shows or games makes hygiene promotion a very participatory activity, as well as lots of fun. With children it’s easier to influence their attitude, since practices aren’t ingrained at their age. Plus we know they can make a difference when they take new knowledge and behaviours home to their parents,” says Shana.

In Pakistan administered Kashmir at Thori Park camp near Muzaffarabad a powerful incentive to personal hygiene has recently been put in place: Thori will be the first camp where the communal washrooms have a supply of hot water. Previously, the areas for washing screened off by tarpaulin had only a cold tap. With winter at its height and temperatures dropping well below freezing at night, the camp’s residents had been bathing less and less with the frigid water.

Dr. Herbert Raaijmakers, UNICEF’s Project Officer for Health in Muzaffarabad explains, "Skin disease is a major concern here. The itchy rash caused by scabies is one of the major problems people report. For curing scabies it’s not only a matter of treatment with medicine. Providing hot water will help them recover from the rash plus we’ll also be showing people how better hygiene can improve their families’ overall health.”

"Unlike most complex emergencies that happen in the tropics, this earthquake occurred where the winter weather gets very cold indeed,” says Bent Kjellerup, UNICEF Project Officer for Water and Sanitation, adding that this means there are limited standard practices for hot water provision in emergency situations. He explains how UNICEF is experimenting here in developing an effective, low-cost method for hot water provision using local materials such as barrels.

The Thori Park tank is a prototype, the first of 60 that UNICEF and partner organizations are working on.. The mechanics are simple.  A barrel is filled to a level just below where its tap is placed. Standing the barrel on a platform, a wood fire is lit below to heat the water.To get their supply, camp residents bring their own bucketful of cold water. Using a funnel, they pour it into the top of the barrel. The cold water descends to the bottom, pushing the heated water up above the level of the tap. Hot water now flows out of the tap to fill the bucket placed below.

After bathing with half a bucket of hot water each Sajid,12, and Michel, 4,  head off damp-haired and shiny-faced towards the camp’s tented school. “We used to have hot showers quite often at home before, but this is our first since the earthquake” comments Munir, 12, as he mops his face and neck with a towel.

Kjellerup concludes, “These hot showers are not just a feel-good treat but also an essential measure for prevention and control of skin diseases. Mothers will now be able to properly disinfect clothing and bedding in the wash – this will promote the wellbeing of the entire family. It’s a good thing that more camp residents will get water soon and have a better chance for making it through the winter healthy.”

Since filing of this story, two more warm bath shelters have become operational. One in Hassa camp, Balakot and the other in Garlat Union Council, Hafizabaad.

Javier Marroquin and Amita Kulkarni contributed to this story from the field.



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