The local
The war in Gaza is an illustrative case study for assessing the role of humanitarian aid in improving MHH in conflict-affected areas. This is because the recent war was peculiar in its sudden onset, high intensity and rapid progression. Adding to the newfound tragedies, people were disenfranchised at the outset, having lived under harsh conditions for years before the war. Approximately 691 300 women and adolescents now face serious challenges in managing menstruation, especially with war-associated stress, increased menstrual abnormalities, and the lack of remedies made available in response to their escalating needs. Of those, nearly over 249 000 are adolescents aged between 10 and 19.10
In global health, the discourse around menstruation during adolescence is based on the ‘hardware and software’ framework, which can also be used to explore the menstrual needs of women across other reproductive age groups.11 Applying this framework to the case of Gaza exposes a menstruation ordeal. Essential needs, such as food and water, have been barely accessible, jeopardising nutrition and limiting water use for washing—both crucial for improved MHH. Similarly, menstrual hygiene products are largely overlooked in non-food item distribution. While UN women estimated that 10 million disposable pads are needed monthly,12 only 6 182 000 have been distributed by the United Nations Population Fund (UNFPA) in 10 months.13 Given the severe lack of menstrual hygiene products, women and adolescents use unhealthy alternatives to sanitary pads and resort to norethisterone to suppress or delay menstruation, despite potential adverse effects.14 15
In view of the poor emergency response, the contextual menstrual preferences shaped by the cultural and religious practices of Palestinians are likely unconsidered.16 17 A local study revealed that Palestinian female university students preferred specific menstruation hygiene products and faced social and physical challenges in managing menstruation.16 Additionally, the constrained physical environment in the overcrowded buildings and tents erected during the war is unfavourable for healthy and dignified menstruation. In Rafah city, an estimated 480 people share a single toilet, for example.14 The sketchy latrine infrastructure hinders gender segregation and fails to accommodate hygiene and privacy, threatening female dignity and leading to inadequate drying, improper disposal and a high risk of infections.12
Atop the hardware problems, the traditional, inadequate education and support that predate the current war might have worsened during wartime. On the one hand, the humanitarian staff, especially males, overseeing and dominating the emergency response lack adequate training in communicating clear, supportive and culturally competent educational messages about menstruation. On the other hand, poor communication about MHH in Palestine makes it even harder to foster a supportive environment. Of note, MHH is challenged by the sociocultural norms of shame and secrecy among Palestinians,18 making discussions around menstruation an exclusive duty of the female family members and limiting the participation of males and people from outside the family.19
The solution to these problems is complex and multifaceted. Stating the obvious, the supply of menstrual hygiene products in aid delivery should be increased to match expected demand. The availability of menstrual hygiene products is a prerequisite for other MHH requirements, including facilities, communication and considerations of privacy and dignity. Once these products are available, the next step is to create the conditions and environments that are conducive to using the products and improving MHH. Without considering the social and psychological needs that shape the sense of the physical space, neither adequate products nor appropriate facilities would suffice, in and of themselves, to respond to the rising menstrual needs. Designing and building acceptable, private and culturally appropriate environments must consider the contextual characteristics and cultural taboos inherent in the structure of the Gazan society. A culturally sensitive response should provide acceptable sanitary kits and washing, drying and disposal methods; and create gender-segregated facilities whereby female dignity is preserved in the presence of men and others. Due to the dearth of previous assessments, these cultural and contextual considerations should be identified by directly consulting with the target population as part of repeated need assessments and postdistribution monitoring surveys. Moreover, humanitarian staff, local informal first responders and the community should engage in manufacturing a menstruation-supportive environment. As men may be the primary receivers of aid in Gaza, addressing male engagement in identifying menstruation needs and communicating educational messages is crucial for an effective emergency response. Male engagement can be improved by addressing knowledge gaps and perceptions about MHH, considering prevailing gender norms and family power dynamics, and channelling communication through influential actors within Gazan society, such as healthcare providers and community and religious leaders.