Sentencia en contra de Orlando Villa Zapata

‘Now people have become more aware of their daughters … they take them to doctors at the early stage of the sickness’ (male, age 28, urban area, U8).

Alauddin and few other respondents mentioned about recent changes in Barguna society in regards of gender inequality. They reported that there is a low but increasing awareness among the inhabitants of the need to value their daughters, sending them to school and giving

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them more opportunities to receive basic needs. Sen (2013) also mentioned in his article on Bangladesh that 'one direction of change is the emphasis that the country has placed on reducing gender inequality in some crucially important respects' (Sen 2013, p 1966).

In Bangladesh, in recent years people are sending more girls to primary school (Chowdhury et al. 2002), which makes Bangladesh one of the few countries in the world where the presence of girls is higher than boys at that level (Sen 2013). This is a great achievement for this country but questions arise about the causation of this move. Rashid claims that parents hope that 'their daughters will attract suitable husbands, but also any schooling or training may make the girls more employable' (Rashid and Michaud 2000, p 55). If so, this might explain the lower presence of female students in the higher secondary level. According to Chowdhury, 'The ''real'' net enrolment rate was found to be 73% at the primary level, it is only 13 % at the higher secondary level' (Chowdhury et al. 2002, p 202). Most of girls, especially in remote areas, are married at age 15 - 16 years.

But there is hope. Nowadays Purdah is no longer a constraint on women to visiting a male doctor in emergency even in the remote Tentulbaria village. Women widely use the 'Borka' (a dress which covers the whole body) and cover their heads and highly prefer female doctors but they are not prohibited from visiting male doctors in an emergency. As, Sardar and Runa mentioned in their interviews, ‘Purdah is not a constraint for healthcare services’ (male, age 18, rural area, R4) and Runa said, ‘There is no restriction for male or female doctors … my mother–in-law does not tell anything about it ... in Barguna city when only male doctors are available we visit them in emergency.’ (Female, age 30, rural area, R6).

Some people are trying to become more aware and change their attitudes. Nazem's quotation from his interview is a case in point: ‘There are still some people who are against the higher education of women … who prohibit women from healthcare services … I myself was also against the higher education of women … But now I meet with educated people and I read newspapers … I became aware … I got rid of that mentality’ (Male, age 28, urban area, U6).

Actually, from my own observations some men do not want to practice the cultural tradition of gender differences. Momsen mentions in her book that 'Even in highly patriarchal societies some men can remain marginal to the dominant order of patriarchy and be open to change' (Momsen 2010, p 106). Due to the 'patriarchal dividend' (Connell 2002) (discussed on page 145) and due to teasing about their ‘manliness’ by their friends, some men cannot come forward for gender equality. Besides, 'in a patriarchal society being male is highly valued, and men value their masculinity' (Kaufman, p 496). The treatment of masculinity and femininity in

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the context of inter-related social variables increases inequalities among inhabitants. Both men and women (discussed in the last section, page 154) reproduce and reinforce gender inequalities, maintaining their gender identities and roles. In the present research, men mentioned their alertness during Sidr for cultural tradition and insecurity. Sending their wife to collect relief may end in their humiliation, like the case study mentioned in Momsen's book. It shows that a man in Tajikistan was taunted and called names by his own father because of his dependency on his wife to maintain the family (Momsen 2010, p 97).

6.13 Conclusion

Reflecting the major issues raised by interviewees during the study, this chapter focuses on several factors and their relationships to healthcare utilization by disaster victims. These factors can be categorized as demographic, behavioural, social, cultural, economic, health and environmental factors, which are inter-related and interact in a complex way, and affect individual’s access to healthcare in disasters significantly (Diagram 6.1).

158 Diagram 6.1

During the immediate post disaster periods healthcare access is extensively affected by environmental factors (e.g. availability of local healthcare facilities and medical relief aid and accessibility of transport systems), combined with other inter-related factors like socio-cultural factors (e.g. gender and cultural attitudes, availability of family and social supports); economic factors (e.g. ability to pay for the treatments); health factors (e.g. severity of injury); and behavioural factors( perception of severity of the conditions and health seeking behaviours).

All these factors, especially economic conditions, socio-cultural and behavioural factors affect the time of healthcare access, place of treatment and completeness of the injury treatments which have been discussed elaborately in this chapter.

Factors affecting healthcare access in disasters

Demographic factors

Behavioural factors

Socio-cultural factors

Economic factors

Health factors

Environmental factors

Healthcare access

Demographic factors: Age, Education

Behavioural factors: Perception of severity of situation, Health seeking behaviour, Awareness

Socio-cultural factors: Gender, Family and social support, Cultural attitude, norms and traditions

Economic factors: Income, Employment, Possession of resources Health factors: Health status; severity of injury, sickness, pregnancy

Environmental (physical and manmade) factors: Severity of cyclone, Local cyclone risk, Location: Urban and rural, Availability of facilities; safe shelters, medical responses, healthcare facilities

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The present research therefore expands on and fleshes out the indications of these factors in existing literature. Most importantly, through its qualitative approach, the current research demonstrates how these factors work together in combination to create great difficulty for the most marginalised people in this region. For example, Few and Tran 2010 focused on economic livelihood, household location and health awareness or education and their inter-relations as the core factors influencing the health impacts of climatic hazards in hazard-prone Vietnam.

Parvin et al. 2008 revealed economic conditions, location and transportation system as significant factors influencing healthcare access in disasters among the disaster prone coastal Islanders in Bangladesh. Uddin and Mazur 2014 in their research revealed the strong influence of socio-economic conditions on healthcare utilization among the Cyclone Sidr survivors, including behavioural factors as perceived susceptibility to post-disaster water-borne diseases linked with health risk communication and education. Boscarino et al. 2005 also mentions behavioural factors, 'they did not believe they had a problem' (Boscarino at al. 2005, p 287) was one of the major reasons for not seeking treatment for mental health problems among the inhabitants of New York City after the World Trade Center Disaster (Boscarino et al. 2005);

this is a significant reason too among the Barguna inhabitants, as described in the previous sections of this chapter. These factors have also been mentioned in other research (Johnson and Galea 2009).

A gendered analysis of women's healthcare utilization and its influencing factors have also been a primary focus of this chapter (Diagram 6.2). These factors have also been mentioned in other research (Puentes-Markides 1992; Paolisso and Leslie 1995; Anwar et al. 2011) (these literatures were reviewed in more detail in Chapter 2 , Section 2.5) .

160 Diagram 6.2

Relationships among the factors influencing healthcare access in disasters:

A gendered analysis

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Analysis of these factors reveals (Diagram 6.2) that socio-cultural factors, especially cultural attitudes to gender relations and responsibilities, has the significant influence on healthcare access of women after disasters, being intensified in poor economic conditions. Women are taught to be dependent and treated as the dependent family members, which makes them victims of social attitudes, beliefs, norms and culture, as well as the adverse impacts of disasters on healthcare access. Inaccessible transport creates difficulties in reaching medical centres, while women's health status such as pregnancy, malnutrition and cultural attitudes (women's dependency for decisions, the need for chaperones, as well as lack of money, resources and autonomy) exaggerate their problems in disasters. The influence of these cultural attitudes is so strong that higher education and income do not assure women's healthcare access. Influence of culture has also been mentioned as important in shaping women's healthcare access in other research (Neumayer and Plümper 2007; Alam and Rahman 2014; Nahar et al. 2014, Sultana 2010).

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