Pakistan's internal refugees have fled danger but have been thrust into alien environments that contradict their beliefs and customs, often resulting in distressing situations, particularly for women.

Heavy fighting between Pakistan's army and the Taliban has forced an estimated 1.5 million people to flee their homes in the northwest of the country, a region where traditional customs are widely followed and where women generally stay indoors and are kept apart from men.

The need to observe purdah - the strict separation of men and women - is causing distress to many female refugees in camps where sanitation facilities are often culturally inappropriate, relief workers say.

Women also face difficulties accessing aid as cultural norms mean they generally do not carry identification and often have not been allowed to have their photographs taken. Documentation is needed to register for aid.

Cultural sensitivities are also prompting internally displaced people to shun camps - where space and facilities require men and women to live in close quarters - in favour of host families or makeshift homes in dilapidated buildings that they view as more private.

"They believe in the strict separation of women and men and they don't like the promiscuity of camps, were people are huddled together in tight quarters," said Sebastien Brack, a spokesman for the International Committee of the Red Cross (ICRC) in Pakistan.

Relief organisations estimate that more than 80 percent of the displaced are staying with host families, often with several large families crowded into one home with limited facilities.

For those inside the camps, conditions are particularly challenging for women.

"The women observe purdah so they sit in the tents the whole day and it's very hot, it's suffocating," said Javeria Ayaz Malik of relief agency ActionAid. "Going to the washroom is a big challenge."

Every effort is being made to construct what aid workers call "purdah-appropriate" toilet blocks in the camps but many blocks do not provide sufficient separation of men and women.

Malik says she has met women in camps - including one pregnant woman - who have preferred to suffer all day and only use the bathroom in the dark. Another woman dug a hole inside the tent and used that as a toilet, she said.

To help the women escape the searing heat inside the tents, humanitarian organisations are trying to build shaded areas that would remain behind a boundary wall, maintaining the women's privacy.

"It is costly to put these kind of structures up but they would contribute to preserving some cultural dignity," said Graham Strong, Pakistan country director for World Vision. "We need to be grappling with these issues and trying to address them."

Brack said the ICRC was pitching fabric canapes above tents to shield the structures, and the women inside them, from the glare of the sun.

"The best we can do is to adapt to societies and offer conditions that tie in with the way they live their lives," he added.

LACK OF DOCUMENTATION

Documentation is another area where cultural norms are leaving the most vulnerable without access to aid or health services.

"Women do not have formal identification and this is a big problem," said Mike Young, Pakistan representative for the International Rescue Committee (IRC). "They can't be registered and they can't access basic services."

Relief organisations are working individually and together to find ways to leapfrog this bureaucratic hurdle.

ActionAid, for example, is taking mobile vans into camps where people can have identification cards made. Women are being treated as a priority, said Malik. World Vision's Strong estimates that about 25 percent of the 1.5 million or so displaced people will be without identity cards, a large majority of whom will be women.

As women strive to adhere to their cultural norms, their health and well being is often compromised, aid workers say.

There is a lack of female medical staff and many women refuse to be seen by a male doctor, often putting themselves at risk. They also struggle to express their needs for basic hygiene or sanitary items.

Many women may have left their homes accompanied by men but now a lot of husbands, brothers and uncles are returning to try and salvage the harvest, leaving women who do not know how to fend for themselves after a lifetime of staying at home.

While aid organisations are doing their best to provide more female doctors, improve conditions in camps and expedite the registration process, they are concerned that women daily face distressing situations because of cultural practices.

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