March 8 is International Women's Day. This day is not used to celebrate women, but to take stock and communicate on the persistent inequalities between women and men. What in everyday language is shortened to “women's day” is actually “women's rights day”. If women/men have been a major issue in recent decades, the results remain mediocre: persistent inequalities, and even will increase with the addition of new climate issues. The United Nations (UN) states:
“Women and girls bear the greatest impacts of the climate crisis, as it amplifies existing gender inequalities and puts women's lives and livelihoods at risk. Around the world, women are more dependent on natural resources, although access to them is less; moreover, they often bear a disproportionate responsibility for obtaining food, water and fuel.
Women will be, are already, the first victims of climate change. Access to natural resources, to school, to management jobs, to security is much more complicated for women. The reasons are multiple and complex, the solutions must be global for the situation of women's rights in the world to improve.
The action of NGOs and associations in the field is essential in this approach to combating gender inequalities. This is a cross-cutting theme that affects all areas: poverty, food, housing, security, education, access to water.
What we propose in this article is to understand the impact of the action of Peuples et Montagnes du Mékong on gender inequalities in Laos.
How does PEMM's medical and health action contribute to the fight against gender inequalities?
Before describing the work carried out by the association in reducing gender inequalities in Laos, it is appropriate to return to the same situation in the country on this issue. The World Health Organization (WHO) closely follows the issue of inequalities in the world: in twenty years, maternal mortality (death of the mother at the time of childbirth or within 42 days of giving birth) decreased by 38%. This drop in maternal mortality also concerns Laos. In 2000, there were 544 deaths per 1000 births. In 2017, Laos recorded 185 deaths per 100,000 births, a decrease of 34% in just 17 years. Significant progress has been made in this area, reducing the situation of future mothers. But this figure is unfortunately still too high. To provide an element of comparison to our readers, France has 8 deaths per 100,000 births. Attachment to birth in the traditional way may explain this high mortality rate: women refuse to give birth in a clinic and culturally remain in their homes to give birth. In the event of a problem, they are then alone and without medical personnel to assist them. As a result, they are not used to consulting a gynecologist. When PEMM organizes clinic visits, our volunteer doctors are faced with two cases:
either no patient comes to the dispensary,
or in the majority of cases, they present significant problems and must be submitted to a district or even provincial hospital.
Even if a woman goes to a clinic to give birth, if her complication is too serious at the time of delivery, it is too late to send her to a hospital that could take care of her (hospital too far away, poor condition of journey…). The work to be done is therefore twofold: firstly on supporting the skills of health centers and on the cultural behavior of future mothers to make them aware of the importance of gynecological follow-up. This gynecological follow-up is not only important during a woman's pregnancy. During the last mission in gynecology in the province of PHONGSALI, our two workers examined a woman with a breast tumor of 5 cm, probably cancerous, which had been evolving for a year. They offered to send this woman to the provincial hospital, or even to the Vientiane hospital if necessary, for a mastectomy. They also saw several cases of sterility of more than 10 years whose exploration and management can only be done in Vientiane.
Young girls and women consult doctors little, if at all, even in the case of their pregnancy. This lack of consultation directly impacts the teams of caregivers who perform few medical procedures. However, practice is essential so that caregivers do not lose the right gestures or the right reflexes. They also see few cases, or when they see some, it is only the most complicated cases and therefore impossible to take care of in a small mountain clinic lacking in resources.
PEMM has chosen as its first action the training of nursing staff in the provinces of OUDOMXAI and PHONGSALI. We have seen that while the situation has greatly improved in 17 years in Laos, the maternal mortality figures are still too high. The divide between urban and rural areas marks these inequalities within the country. Rural areas are more often difficult to access and very quickly make health services inaccessible in the event of bad weather and impassable tracks. In this case, it is much more difficult to access care. The medical mission of the Mobile Boat Clinic in which PEMM participated responds to this problem: nine villages in the district of Pak Beng are completely isolated. Waterways are the only ones that provide access to these villages. It is then impossible for the 5,000 inhabitants of these villages to benefit from the district hospital, the so calm Mekong river suddenly appears as impassable, symbol of this divide between urban and rural. The Mobile Boat Clinic was an exploratory mission that took place in November 2022 to take stock of the medical needs of the population and to think about an effective long-term solution. Some people had to walk 5 hours through the forest to benefit from the consultations of the international medical team.
Medically speaking, Lao caregivers know no less than French caregivers, they lack material, human and economic means: material because they are extremely limited (most often with the absence of water in dispensaries), human because the number of carers is limited (0.4 doctors per 1000 inhabitants), economic because all the carers are not paid for their work. This is the reason why the latter cannot spend all their time at the dispensary and why they can even less benefit from continuing education.
PEMM has decided to act on material and economic resources by offering medical training and support for caregivers. As you know, the association's program is to train caregivers and accompany them to the dispensaries. These missions also allow French doctors to collect the expression of the material needs of caregivers to which we try to respond as much as possible. Giving the skills and resources to all caregivers, even those most remote, means increasing the possibilities of care. Currently, 64% of births in Laos are attended by health personnel (2017 figure). As you can imagine, this 64% is not evenly distributed across the territory, and in the provinces of OUDOMXAI and PHONGSALY, PEMM works with the remaining 36% of women who continue to give birth alone at home. By deciding to work on the skills of caregivers, PEMM improves the health situation of dispensaries, the care of patients by trained caretakers. These trainings make caregivers aware of their role as sensitizers with patients.
Training is a tremendous lever for reducing maternal mortality. But this is not the only form of inequality on which medical training acts. In a very strongly culturally marked society, women who are followed in gynecology are by…women. Training in gynecology increases the skills of doctors, midwives and nurses. It is essential that they feel competent and valued in order to be able to follow up on their patient and assume positions of responsibility in health centres.
Where training is an action directly linked to the question of improving the quality of care, the water supply worksites act on the question of health means of action.
PEMM has established these two actions (training and water supply sites) in complementarity. The idea is to be able to offer better care in a better environment. It is important for the population to have access to a secure water point: clean and drinkable water without risk to health. Currently, only 18% of the population of Laos has access to a secure water point (figure dating from 2017). The supply works carried out by PEMM are an effective response to water management and the reduction of water-borne diseases among a vulnerable population, i.e. the elderly, children and women. Making water accessible is also a way to fight against gender inequality. In Asia, the average time to fetch water is 21 minutes… in the dry season. This figure is much less impressive than for Africa, but it is revealing of the reality of the populations of Laos: water is supplied to those who have the time to fetch it. He or she, because women and young girls are presupposed to this task.
The young girls fetch water for the family (for drinking, cooking, washing). The further the water to fetch, the more the girl has to go back and forth to get enough water. This time spent fetching water is time lost on the school benches. The weight of the water resource weighs on young girls and on the possibilities of accessing studies in a way that is completely foreign to boys. Add to that a lack of gynecological follow-up and early pregnancies, equality of opportunity between genders is impossible, at least as long as such conditions exist. With climate change, Laos will experience stronger rainy season episodes and more extreme drought episodes. Women will be direct victims of these changes, since they will then have to spend more time fetching water.
PEMM had also carried out a dry toilet project in 2011, the absence of sanitary facilities raises questions of hygiene for menstruating girls and young girls. In the absence of sanitary facilities at school, for example, young girls at the time of their menstruation stay at home, or hold back all day, increasing the risk of urinary tract infection. The difficulty of access to natural resources (here water) is a constraint that directly impacts women in various areas of their lives.
These inequalities in access to care, natural resources and health infrastructure are increasing and fueling gender inequalities, in Laos as everywhere else in the world. The action of PEMM considers the problem in a global way, with a response on caregivers for an empowerment and an increase in skills, for a better follow-up and care of women during their life and in their birth project while taking into account account the environment in which these actions take place. The fact is that gender inequality is a complex and global problem. Each response taken individually will not be able to change the situation, it requires a convergence of actions with a thinking of complex projects and on multiple scales.
On this day of March 8, 2023, we wanted to focus on the responses provided by PEMM in Laos in a medical and health context, on the path taken, and on the challenges that we still have to respond to.
I will end this article by reminding you, as a reader, that to help us fight against these inequalities, you can donate, become a member, become a volunteer for the association... choose your field of action and join us.
To all women,
Mylène Geliot