Typhoon Haiyan recovery: progress and challenges
2014; Elsevier BV; Volume: 383; Issue: 9924 Linguagem: Inglês
10.1016/s0140-6736(14)60590-0
ISSN1474-547X
Autores Tópico(s)Disaster Response and Management
Resumo5 months on, progress has been made in the provision of health services for those affected by Super Typhoon Haiyan but vital gaps remain. Sima Barmania reports.On Nov 8, 2013, the Philippines experienced its most devastating catastrophe in 20 years—Super Typhoon Haiyan. The typhoon, with sustained wind speeds of around 150 mph, was cataclysmic and resulted in the deaths of more than 6200 people and the displacement of 4 million. In total, the lives of some 14 million Filipinos were affected by the destruction. Despite the initial international attention, nearly 5 months on, the country is still grappling with pressing health needs.Shattered health systemOne of the areas most affected by Typhoon Haiyan is the city of Tacloban, which Gloria Fabregas describes as being in a transitory phase from “emergency to recovery”. As head of the health cluster of the city, she explains some of her concerns to The Lancet: “The facilities are not fully functional, especially not in maternal care; if this is not taken care of mothers may deliver at home, which is high risk.”The overarching need to re-establish health facilities in typhoon-hit areas is evident when visiting some of the structures that have been damaged, such as the Albino M Duran Memorial Hospital in Balangiga, Eastern Samar province. Tragically, the renovations for the hospital were almost complete before Typhoon Haiyan hit, but now the building is so damaged that a temporary tented field hospital has been erected several metres away from the permanent site.It soon becomes apparent that the past few months have been deeply emotional for Benedicto Garcia, chief of the hospital and president of Eastern Samar medical society. As he guides The Lancet through the damaged hospital's murky, wet corridors, in mid conversation his voice breaks and his eyes well up with tears. It is not customary in Filipino culture to express such sorrow, “even if we are hurting, we have to smile”, says Garcia despondently.He says that originally the hospital was licensed to cater for outpatients but he was “not content to just do that” and decided to include emergency consultations. “If patients are referred to bigger hospitals they will be displaced from families and have no money”, he explains.The tented facilities in the hospital grounds lay in stark contrast with the site's newest arrival, the eagerly awaited clinic housed in a shipping container, aptly named Clinic In A Can. Daniel White is the international missions coordinator for Clinic In A Can, a division of medical missions nonprofit Hospitals of Hope. The container, which has a solar panelled roof, is designed for use in remote settings and has previously been used in other disaster areas, “everything ships inside a container”, says White. Expanding further, he says, “It all started with Haiti; it's a very sturdy structure that can be used right away. This will be here in 30, 40, 50 years.”Once fully set up, the facility will be able to provide caesarean sections and will help to fill one of the major gaps in health in the region—maternal health.Fabregas in Tacloban says the over-arching priority areas are health system strengthening, resumption of service delivery, and the establishment of a health information management system. However, she is also cognisant of the constant need to balance services for infectious diseases and non-communicable diseases.These fundamental issues are reiterated by Nevio Zagaria, the WHO Team leader for Emergency and Humanitarian action. WHO is working with the Department of Health to assist them to “manage the recovery process of the health sector”, says Zagaria, while also ensuring the “rehabilitation of the health system”. They are assessing how best to open health facilities that have been destroyed, which is achieved, he adds, “through fixing infrastructure, planning, and avoiding overlap”.Many hospital and health facilities still need rebuilding or repairing in typhoon-hit areasView Large Image Copyright © 2014 George Calvelo/NurPhoto/NurPhoto/CorbisConcurrently, WHO is providing technical support with respect to infectious disease surveillance. 3 weeks after the disaster a mass measles vaccination campaign was implemented where, prior to the typhoon, routine coverage had been low. WHO is also watchful over dengue fever, which Zagaria describes as “not over the threshold of reported cases” and for cholera, they have had “no cases so far but have an active surveillance system”. Nevertheless, Zagaria says, “the challenges in public health are not in terms of infectious diseases, although we need to be very vigilant.”Hard sellMany of the birthing facilities were heavily damaged during the typhoon and “what was weak before the typhoon [referring to maternal and neonatal health], is weak after”, says Zagaria.Ronnel Villas is the UN Population Fund's (UNFPA) humanitarian coordinator in Tacloban. He explains that they are operating with limited resources: “Reproductive health is not easy to sell in humanitarian agencies' and there are questions as to whether reproductive health should be part of the humanitarian response agenda at all. The result is we have to cut down our interventions for women”, says Villas, a native to Tacloban who arrived in the city just 3 days after the typhoon. “It's hard to sleep at night when you know you could have saved more women.”Apart from financing, some of the challenges include loss of infrastructure and staff and the loss of information files, many of which were washed away during the typhoon. This destruction of medical records meant that women who were pregnant or lactating had to be manually identified by the midwives in villages.In view of the lack of resources, innovative approaches have been used such as emergency tricycle ambulances—a motorcycle with a sidecar and padded bed, designed to transport pregnant women back and forth to hospitals and referral centres.In Palo municipality, another container with medical equipment has temporarily become an Emergency Maternity Unit (EMU) until the provincial hospital in Leyte is repaired. The clinic has been fully functioning since late December. They have handled 56 cases so far, 41 of which were caesarean sections, says Maria Cazon, the clinic manager. The service is free for clients and hospital patients are brought from Leyte provincial hospital to the EMU. “If this was not here, they [surrounding hospitals] would be overloaded and there would be an increase in maternal mortality”, says Cazon but states that a major drawback is the absence of a neonatal intensive care unit.Furthermore, in an attempt to maximise resources and reach, UNFPA are working with other organisations such as Save the Children and Plan International to undertake medical missions for reproductive health.Terence Francisco of Save the Children oversees one such mission, which offers antenatal and family planning services, distributes reproductive health kits, and provides health information seminars on issues such as HIV and breastfeeding. Francisco explains that they also cater to the local adolescents and young adults “targeting 10 to 24-year-olds as a way to curb teenage pregnancies”.Another reproductive health medical mission in Eastern Samar is run by Plan International. This particular facility is far less shielded than the one run by Francisco, with a simple tarpaulin roof, which was thrashing against the wind when The Lancet visits.Estrella Serrano, a health and nutritional programme manager at Plan International, says: “We cater to pregnant and lactating mothers and children from 0 to 59 months and lecture mothers on proper nutritional supplements and screening using mid-upper arm circumference.” In addition the non-governmental organisation trains “service providers in the clinical management of acute and severe malnutrition”. The World Food Programme is supporting them with provision of high-energy biscuits for children; any severe cases of malnutrition get referred to provincial centres. The only permanent structure available for use for the mission is the wooden chapel a few metres along a short path behind which the midwives now use as an examination room and was the only edifice to withstand the typhoon in the local area.Waiting to be seen is 31-year-old Issidora, who is pregnant with her fourth child, patiently sitting on a church pew next to the other ladies also waiting to be seen by the midwife. She was 2 months pregnant when the typhoon hit. “The wind was so strong I almost got hit by parts of the houses. At that time, I was with the kids and the house was collapsing”, she says recounting the event. Thankfully, neither her nor her children were hurt and her pregnancy has gone smoothly since then. She says she has visited the mission several times.Safe spacesIn the aftermath of the typhoon, cases of gender-based violence have been reported and there are fears of human trafficking, which is sadly familiar in times of crisis and displacement. Efforts have been made to prevent such events occurring by raising awareness, providing information, and reducing women's vulnerability.One such means of prevention is the incorporation of women-friendly spaces, areas where women can come together for a particular activity, be shielded from the rain, and learn about protection from gender-based violence, while also acting as an entry point for other services.Temporary accommodation such as the evacuation tent sites and bunkhouses can be of particular concern, but by gender mainstreaming in relief operations and forward planning, the risk of gender based violence can be mitigated. Guiuan is the municipality where Typhoon Haiyan made its first landfall. It now hosts an expansive tent city and the women-friendly spaces here are “an opportunity to provide information”, says Penina Gathuri, gender based violence field coordinator at UNFPA, seconded from the Norwegian Refugee Council.Gathuri describes the spaces as providing a safe place to talk about protection, laws, and the rights of women. Female police officers patrol the vicinity. 22-year-old principal inspector Chervy Verano and her colleagues have thus far been effective as they have “not had any cases in this evacuation site”, she says. Areas that are particularly susceptible are toilets and bathing facilities which are dark, confined solitary places. But Verano is always watchful, “for me all places are vulnerable”. Night time poses extra risk and to remedy this there is a strict curfew from 10 pm to 4 am with perimeter lighting and voluntary security.Guiuan's tent city has women-friendly spaces to prevent gender-based violence and provide servicesView Large Image Copyright © 2014 Sima BarmaniaHowever, another accommodation site, the Motorcross bunkhouse in Tacloban offers less comprehensive defences; nine to ten people, often from two different families, live in one bunk house. Residents here are still waiting for electricity and lighting. Elsewhere in Tacloban, the women's shelter conveys a bleaker outcome, explains social worker Carmella Bastez. Bastez shows The Lancet the logbook for the shelter over the previous months whereby the most common admissions after the typhoon are children or minors who have been sexually abused, often by someone in their family.Constant fearAnother health burden of the typhoon is mental health, says Zagaria. WHO is training non-specialised doctors and nurses to deal with mental health, emphasising that such services were a substantial gap in the health system before the typhoon.Sharilee Gaspay-Mauro, a psychologist who works for International Emergency Development Aid, is well aware of the trauma caused by the typhoon and says that “one of the needs identified was to conduct psychological support”. Expanding further: “We went to areas greatly affected by the typhoon. If it rains, they [the children] start crying and immediately ask about the nearest evacuation site.” In addition, some experience flashbacks and sleep disturbances. “There is constant fear”, says Gaspay-Mauro.Part of the support includes psychological first aid—“we ask how they are feeling and gain information on their immediate needs”, says Gaspay-Mauro. “The problem is we don't have mental health facilities in Tacloban”, she says.Undoubtedly, over the past 5 months substantial progress has been made in health provision, attributed to the local ethos of resilience and resourcefulness as much as innovation, collaboration, and international support. However, as well as maintaining achievements so far, more needs to be done to fill in the service gaps. As Villas notes, there are “primary needs that are yet to be addressed”. For The Lancet News podcast see http://www.thelancet.com/lancet-news-audio/SB received funding from the UN Population Fund to assist with domestic travel and accommodation in the Philippines for this report 5 months on, progress has been made in the provision of health services for those affected by Super Typhoon Haiyan but vital gaps remain. Sima Barmania reports. On Nov 8, 2013, the Philippines experienced its most devastating catastrophe in 20 years—Super Typhoon Haiyan. The typhoon, with sustained wind speeds of around 150 mph, was cataclysmic and resulted in the deaths of more than 6200 people and the displacement of 4 million. In total, the lives of some 14 million Filipinos were affected by the destruction. Despite the initial international attention, nearly 5 months on, the country is still grappling with pressing health needs. Shattered health systemOne of the areas most affected by Typhoon Haiyan is the city of Tacloban, which Gloria Fabregas describes as being in a transitory phase from “emergency to recovery”. As head of the health cluster of the city, she explains some of her concerns to The Lancet: “The facilities are not fully functional, especially not in maternal care; if this is not taken care of mothers may deliver at home, which is high risk.”The overarching need to re-establish health facilities in typhoon-hit areas is evident when visiting some of the structures that have been damaged, such as the Albino M Duran Memorial Hospital in Balangiga, Eastern Samar province. Tragically, the renovations for the hospital were almost complete before Typhoon Haiyan hit, but now the building is so damaged that a temporary tented field hospital has been erected several metres away from the permanent site.It soon becomes apparent that the past few months have been deeply emotional for Benedicto Garcia, chief of the hospital and president of Eastern Samar medical society. As he guides The Lancet through the damaged hospital's murky, wet corridors, in mid conversation his voice breaks and his eyes well up with tears. It is not customary in Filipino culture to express such sorrow, “even if we are hurting, we have to smile”, says Garcia despondently.He says that originally the hospital was licensed to cater for outpatients but he was “not content to just do that” and decided to include emergency consultations. “If patients are referred to bigger hospitals they will be displaced from families and have no money”, he explains.The tented facilities in the hospital grounds lay in stark contrast with the site's newest arrival, the eagerly awaited clinic housed in a shipping container, aptly named Clinic In A Can. Daniel White is the international missions coordinator for Clinic In A Can, a division of medical missions nonprofit Hospitals of Hope. The container, which has a solar panelled roof, is designed for use in remote settings and has previously been used in other disaster areas, “everything ships inside a container”, says White. Expanding further, he says, “It all started with Haiti; it's a very sturdy structure that can be used right away. This will be here in 30, 40, 50 years.”Once fully set up, the facility will be able to provide caesarean sections and will help to fill one of the major gaps in health in the region—maternal health.Fabregas in Tacloban says the over-arching priority areas are health system strengthening, resumption of service delivery, and the establishment of a health information management system. However, she is also cognisant of the constant need to balance services for infectious diseases and non-communicable diseases.These fundamental issues are reiterated by Nevio Zagaria, the WHO Team leader for Emergency and Humanitarian action. WHO is working with the Department of Health to assist them to “manage the recovery process of the health sector”, says Zagaria, while also ensuring the “rehabilitation of the health system”. They are assessing how best to open health facilities that have been destroyed, which is achieved, he adds, “through fixing infrastructure, planning, and avoiding overlap”.Concurrently, WHO is providing technical support with respect to infectious disease surveillance. 3 weeks after the disaster a mass measles vaccination campaign was implemented where, prior to the typhoon, routine coverage had been low. WHO is also watchful over dengue fever, which Zagaria describes as “not over the threshold of reported cases” and for cholera, they have had “no cases so far but have an active surveillance system”. Nevertheless, Zagaria says, “the challenges in public health are not in terms of infectious diseases, although we need to be very vigilant.” One of the areas most affected by Typhoon Haiyan is the city of Tacloban, which Gloria Fabregas describes as being in a transitory phase from “emergency to recovery”. As head of the health cluster of the city, she explains some of her concerns to The Lancet: “The facilities are not fully functional, especially not in maternal care; if this is not taken care of mothers may deliver at home, which is high risk.” The overarching need to re-establish health facilities in typhoon-hit areas is evident when visiting some of the structures that have been damaged, such as the Albino M Duran Memorial Hospital in Balangiga, Eastern Samar province. Tragically, the renovations for the hospital were almost complete before Typhoon Haiyan hit, but now the building is so damaged that a temporary tented field hospital has been erected several metres away from the permanent site. It soon becomes apparent that the past few months have been deeply emotional for Benedicto Garcia, chief of the hospital and president of Eastern Samar medical society. As he guides The Lancet through the damaged hospital's murky, wet corridors, in mid conversation his voice breaks and his eyes well up with tears. It is not customary in Filipino culture to express such sorrow, “even if we are hurting, we have to smile”, says Garcia despondently. He says that originally the hospital was licensed to cater for outpatients but he was “not content to just do that” and decided to include emergency consultations. “If patients are referred to bigger hospitals they will be displaced from families and have no money”, he explains. The tented facilities in the hospital grounds lay in stark contrast with the site's newest arrival, the eagerly awaited clinic housed in a shipping container, aptly named Clinic In A Can. Daniel White is the international missions coordinator for Clinic In A Can, a division of medical missions nonprofit Hospitals of Hope. The container, which has a solar panelled roof, is designed for use in remote settings and has previously been used in other disaster areas, “everything ships inside a container”, says White. Expanding further, he says, “It all started with Haiti; it's a very sturdy structure that can be used right away. This will be here in 30, 40, 50 years.” Once fully set up, the facility will be able to provide caesarean sections and will help to fill one of the major gaps in health in the region—maternal health. Fabregas in Tacloban says the over-arching priority areas are health system strengthening, resumption of service delivery, and the establishment of a health information management system. However, she is also cognisant of the constant need to balance services for infectious diseases and non-communicable diseases. These fundamental issues are reiterated by Nevio Zagaria, the WHO Team leader for Emergency and Humanitarian action. WHO is working with the Department of Health to assist them to “manage the recovery process of the health sector”, says Zagaria, while also ensuring the “rehabilitation of the health system”. They are assessing how best to open health facilities that have been destroyed, which is achieved, he adds, “through fixing infrastructure, planning, and avoiding overlap”. Concurrently, WHO is providing technical support with respect to infectious disease surveillance. 3 weeks after the disaster a mass measles vaccination campaign was implemented where, prior to the typhoon, routine coverage had been low. WHO is also watchful over dengue fever, which Zagaria describes as “not over the threshold of reported cases” and for cholera, they have had “no cases so far but have an active surveillance system”. Nevertheless, Zagaria says, “the challenges in public health are not in terms of infectious diseases, although we need to be very vigilant.” Hard sellMany of the birthing facilities were heavily damaged during the typhoon and “what was weak before the typhoon [referring to maternal and neonatal health], is weak after”, says Zagaria.Ronnel Villas is the UN Population Fund's (UNFPA) humanitarian coordinator in Tacloban. He explains that they are operating with limited resources: “Reproductive health is not easy to sell in humanitarian agencies' and there are questions as to whether reproductive health should be part of the humanitarian response agenda at all. The result is we have to cut down our interventions for women”, says Villas, a native to Tacloban who arrived in the city just 3 days after the typhoon. “It's hard to sleep at night when you know you could have saved more women.”Apart from financing, some of the challenges include loss of infrastructure and staff and the loss of information files, many of which were washed away during the typhoon. This destruction of medical records meant that women who were pregnant or lactating had to be manually identified by the midwives in villages.In view of the lack of resources, innovative approaches have been used such as emergency tricycle ambulances—a motorcycle with a sidecar and padded bed, designed to transport pregnant women back and forth to hospitals and referral centres.In Palo municipality, another container with medical equipment has temporarily become an Emergency Maternity Unit (EMU) until the provincial hospital in Leyte is repaired. The clinic has been fully functioning since late December. They have handled 56 cases so far, 41 of which were caesarean sections, says Maria Cazon, the clinic manager. The service is free for clients and hospital patients are brought from Leyte provincial hospital to the EMU. “If this was not here, they [surrounding hospitals] would be overloaded and there would be an increase in maternal mortality”, says Cazon but states that a major drawback is the absence of a neonatal intensive care unit.Furthermore, in an attempt to maximise resources and reach, UNFPA are working with other organisations such as Save the Children and Plan International to undertake medical missions for reproductive health.Terence Francisco of Save the Children oversees one such mission, which offers antenatal and family planning services, distributes reproductive health kits, and provides health information seminars on issues such as HIV and breastfeeding. Francisco explains that they also cater to the local adolescents and young adults “targeting 10 to 24-year-olds as a way to curb teenage pregnancies”.Another reproductive health medical mission in Eastern Samar is run by Plan International. This particular facility is far less shielded than the one run by Francisco, with a simple tarpaulin roof, which was thrashing against the wind when The Lancet visits.Estrella Serrano, a health and nutritional programme manager at Plan International, says: “We cater to pregnant and lactating mothers and children from 0 to 59 months and lecture mothers on proper nutritional supplements and screening using mid-upper arm circumference.” In addition the non-governmental organisation trains “service providers in the clinical management of acute and severe malnutrition”. The World Food Programme is supporting them with provision of high-energy biscuits for children; any severe cases of malnutrition get referred to provincial centres. The only permanent structure available for use for the mission is the wooden chapel a few metres along a short path behind which the midwives now use as an examination room and was the only edifice to withstand the typhoon in the local area.Waiting to be seen is 31-year-old Issidora, who is pregnant with her fourth child, patiently sitting on a church pew next to the other ladies also waiting to be seen by the midwife. She was 2 months pregnant when the typhoon hit. “The wind was so strong I almost got hit by parts of the houses. At that time, I was with the kids and the house was collapsing”, she says recounting the event. Thankfully, neither her nor her children were hurt and her pregnancy has gone smoothly since then. She says she has visited the mission several times. Many of the birthing facilities were heavily damaged during the typhoon and “what was weak before the typhoon [referring to maternal and neonatal health], is weak after”, says Zagaria. Ronnel Villas is the UN Population Fund's (UNFPA) humanitarian coordinator in Tacloban. He explains that they are operating with limited resources: “Reproductive health is not easy to sell in humanitarian agencies' and there are questions as to whether reproductive health should be part of the humanitarian response agenda at all. The result is we have to cut down our interventions for women”, says Villas, a native to Tacloban who arrived in the city just 3 days after the typhoon. “It's hard to sleep at night when you know you could have saved more women.” Apart from financing, some of the challenges include loss of infrastructure and staff and the loss of information files, many of which were washed away during the typhoon. This destruction of medical records meant that women who were pregnant or lactating had to be manually identified by the midwives in villages. In view of the lack of resources, innovative approaches have been used such as emergency tricycle ambulances—a motorcycle with a sidecar and padded bed, designed to transport pregnant women back and forth to hospitals and referral centres. In Palo municipality, another container with medical equipment has temporarily become an Emergency Maternity Unit (EMU) until the provincial hospital in Leyte is repaired. The clinic has been fully functioning since late December. They have handled 56 cases so far, 41 of which were caesarean sections, says Maria Cazon, the clinic manager. The service is free for clients and hospital patients are brought from Leyte provincial hospital to the EMU. “If this was not here, they [surrounding hospitals] would be overloaded and there would be an increase in maternal mortality”, says Cazon but states that a major drawback is the absence of a neonatal intensive care unit. Furthermore, in an attempt to maximise resources and reach, UNFPA are working with other organisations such as Save the Children and Plan International to undertake medical missions for reproductive health. Terence Francisco of Save the Children oversees one such mission, which offers antenatal and family planning services, distributes reproductive health kits, and provides health information seminars on issues such as HIV and breastfeeding. Francisco explains that they also cater to the local adolescents and young adults “targeting 10 to 24-year-olds as a way to curb teenage pregnancies”. Another reproductive health medical mission in Eastern Samar is run by Plan International. This particular facility is far less shielded than the one run by Francisco, with a simple tarpaulin roof, which was thrashing against the wind when The Lancet visits. Estrella Serrano, a health and nutritional programme manager at Plan International, says: “We cater to pregnant and lactating mothers and children from 0 to 59 months and lecture mothers on proper nutritional supplements and screening using mid-upper arm circumference.” In addition the non-governmental organisation trains “service providers in the clinical management of acute and severe malnutrition”. The World Food Programme is supporting them with provision of high-energy biscuits for children; any severe cases of malnutrition get referred to provincial centres. The only permanent structure available for use for the mission is the wooden chapel a few metres along a short path behind which the midwives now use as an examination room and was the only edifice to withstand the typhoon in the local area. Waiting to be seen is 31-year-old Issidora, who is pregnant with her fourth child, patiently sitting on a church pew next to the other ladies also waiting to be seen by the midwife. She was 2 months pregnant when the typhoon hit. “The wind was so strong I almost got hit by parts of the houses. At that time, I was with the kids and the house was collapsing”, she says recounting the event. Thankfully, neither her nor her children were hurt and her pregnancy has gone smoothly since then. She says she has visited the mission several times. Safe spacesIn the aftermath of the typhoon, cases of gender-based violence have been reported and there are fears of human trafficking, which is sadly familiar in times of crisis and displacement. Efforts have been made to prevent such events occurring by raising awareness, providing information, and reducing women's vulnerability.One such means of prevention is the incorporation of women-friendly spaces, areas where women can come together for a particular activity, be shielded from the rain, and learn about protection from gender-based violence, while also acting as an entry point for other services.Temporary accommodation such as the evacuation tent sites and bunkhouses can be of particular concern, but by gender mainstreaming in relief operations and forward planning, the risk of gender based violence can be mitigated. Guiuan is the municipality where Typhoon Haiyan made its first landfall. It now hosts an expansive tent city and the women-friendly spaces here are “an opportunity to provide information”, says Penina Gathuri, gender based violence field coordinator at UNFPA, seconded from the Norwegian Refugee Council.Gathuri describes the spaces as providing a safe place to talk about protection, laws, and the rights of women. Female police officers patrol the vicinity. 22-year-old principal inspector Chervy Verano and her colleagues have thus far been effective as they have “not had any cases in this evacuation site”, she says. Areas that are particularly susceptible are toilets and bathing facilities which are dark, confined solitary places. But Verano is always watchful, “for me all places are vulnerable”. Night time poses extra risk and to remedy this there is a strict curfew from 10 pm to 4 am with perimeter lighting and voluntary security.However, another accommodation site, the Motorcross bunkhouse in Tacloban offers less comprehensive defences; nine to ten people, often from two different families, live in one bunk house. Residents here are still waiting for electricity and lighting. Elsewhere in Tacloban, the women's shelter conveys a bleaker outcome, explains social worker Carmella Bastez. Bastez shows The Lancet the logbook for the shelter over the previous months whereby the most common admissions after the typhoon are children or minors who have been sexually abused, often by someone in their family. In the aftermath of the typhoon, cases of gender-based violence have been reported and there are fears of human trafficking, which is sadly familiar in times of crisis and displacement. Efforts have been made to prevent such events occurring by raising awareness, providing information, and reducing women's vulnerability. One such means of prevention is the incorporation of women-friendly spaces, areas where women can come together for a particular activity, be shielded from the rain, and learn about protection from gender-based violence, while also acting as an entry point for other services. Temporary accommodation such as the evacuation tent sites and bunkhouses can be of particular concern, but by gender mainstreaming in relief operations and forward planning, the risk of gender based violence can be mitigated. Guiuan is the municipality where Typhoon Haiyan made its first landfall. It now hosts an expansive tent city and the women-friendly spaces here are “an opportunity to provide information”, says Penina Gathuri, gender based violence field coordinator at UNFPA, seconded from the Norwegian Refugee Council. Gathuri describes the spaces as providing a safe place to talk about protection, laws, and the rights of women. Female police officers patrol the vicinity. 22-year-old principal inspector Chervy Verano and her colleagues have thus far been effective as they have “not had any cases in this evacuation site”, she says. Areas that are particularly susceptible are toilets and bathing facilities which are dark, confined solitary places. But Verano is always watchful, “for me all places are vulnerable”. Night time poses extra risk and to remedy this there is a strict curfew from 10 pm to 4 am with perimeter lighting and voluntary security. However, another accommodation site, the Motorcross bunkhouse in Tacloban offers less comprehensive defences; nine to ten people, often from two different families, live in one bunk house. Residents here are still waiting for electricity and lighting. Elsewhere in Tacloban, the women's shelter conveys a bleaker outcome, explains social worker Carmella Bastez. Bastez shows The Lancet the logbook for the shelter over the previous months whereby the most common admissions after the typhoon are children or minors who have been sexually abused, often by someone in their family. Constant fearAnother health burden of the typhoon is mental health, says Zagaria. WHO is training non-specialised doctors and nurses to deal with mental health, emphasising that such services were a substantial gap in the health system before the typhoon.Sharilee Gaspay-Mauro, a psychologist who works for International Emergency Development Aid, is well aware of the trauma caused by the typhoon and says that “one of the needs identified was to conduct psychological support”. Expanding further: “We went to areas greatly affected by the typhoon. If it rains, they [the children] start crying and immediately ask about the nearest evacuation site.” In addition, some experience flashbacks and sleep disturbances. “There is constant fear”, says Gaspay-Mauro.Part of the support includes psychological first aid—“we ask how they are feeling and gain information on their immediate needs”, says Gaspay-Mauro. “The problem is we don't have mental health facilities in Tacloban”, she says.Undoubtedly, over the past 5 months substantial progress has been made in health provision, attributed to the local ethos of resilience and resourcefulness as much as innovation, collaboration, and international support. However, as well as maintaining achievements so far, more needs to be done to fill in the service gaps. As Villas notes, there are “primary needs that are yet to be addressed”. For The Lancet News podcast see http://www.thelancet.com/lancet-news-audio/SB received funding from the UN Population Fund to assist with domestic travel and accommodation in the Philippines for this report Another health burden of the typhoon is mental health, says Zagaria. WHO is training non-specialised doctors and nurses to deal with mental health, emphasising that such services were a substantial gap in the health system before the typhoon. Sharilee Gaspay-Mauro, a psychologist who works for International Emergency Development Aid, is well aware of the trauma caused by the typhoon and says that “one of the needs identified was to conduct psychological support”. Expanding further: “We went to areas greatly affected by the typhoon. If it rains, they [the children] start crying and immediately ask about the nearest evacuation site.” In addition, some experience flashbacks and sleep disturbances. “There is constant fear”, says Gaspay-Mauro. Part of the support includes psychological first aid—“we ask how they are feeling and gain information on their immediate needs”, says Gaspay-Mauro. “The problem is we don't have mental health facilities in Tacloban”, she says. Undoubtedly, over the past 5 months substantial progress has been made in health provision, attributed to the local ethos of resilience and resourcefulness as much as innovation, collaboration, and international support. However, as well as maintaining achievements so far, more needs to be done to fill in the service gaps. As Villas notes, there are “primary needs that are yet to be addressed”. For The Lancet News podcast see http://www.thelancet.com/lancet-news-audio/SB received funding from the UN Population Fund to assist with domestic travel and accommodation in the Philippines for this report For The Lancet News podcast see http://www.thelancet.com/lancet-news-audio/SB received funding from the UN Population Fund to assist with domestic travel and accommodation in the Philippines for this report For The Lancet News podcast see http://www.thelancet.com/lancet-news-audio/ SB received funding from the UN Population Fund to assist with domestic travel and accommodation in the Philippines for this report
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