Safe and clean public toilets: Women’s health, Nation’s progress

“I measure the progress of a community with the degree of progress women have achieved.”

                                                                                                            Dr. B. R. Ambedkar

Dr. Amita Mukhopadhyay, MBBS, MD.

Professor, IIHMR Bangalore 

amita.mukho@iihmrbangalore.edu.in

One hundred years ago, in the 1920s, the architect of our Constitution advocated for women’s education and equal participation in society. It was Dr. B. R. Ambedkar’s enlightened feminist viewpoint, and his astute arguments and defence that culminated in the passage of the Bombay Maternity Benefits Act 1929.(1) This year, after a century of slow yet determined progress, the Nari Shakti Vandan Adhiniyam Bill has been near unanimously endorsed and passed, assuring women a fair representation in the legislative bodies of the Indian government.(2)

Despite such encouraging progress, women’s advancement and inclusion at the policy level is a panoptic achievement that serves to etch sharper, our keenly felt and long neglected lesser wants. Given the unavoidable compulsions of the human condition and especially feminine physiology, accessible and hygienic sanitary facilities can either reinforce and boost us, or, when lacking, they can become the nail that brings about an army’s downfall.

According to the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF), close to a third of schools globally do not have safe and adequate toilets and drinking water.(3) The WHO estimates that nearly a million deaths every year in middle and low income countries occur due to unclean water and poor sanitation. Unhygienic sanitary facilities also play a major role in causing several bacterial and parasitic diseases in addition to the cases of malnutrition caused by repeated infections and diarrhoea, thus perpetuating a vicious cycle of poverty, infections and malnutrition.(4)

The impact of the failure to ensure clean, safe, and dignified sanitary facilities for women and girls extends beyond immediate distress and disease. It is an established fact that in India and around the world, girl students drop out of school at shameful rates because of the lack of sanitation and menstrual hygiene facilities.(5)

My own lived experience as a doctor and a woman highlights the critical importance of safe and hygienic toilets for women. I have personally suffered the shock and steep learning curve of crowded, poorly maintained and often overflowing toilets as an MBBS scholar navigating life and studies in an ill-maintained hostel. As an intern on duty managing a 36-hour inpatient ward shift while suffering from acute food poisoning, I have struggled with toilets that did not have a dependable water supply. I have listened to and empathised with hundreds of women patients living with constant pain and sickness because of urinary tract infections brought on by the lack of access to hygienic toilet facilities. 

For working women, the lack of safe and clean sanitation indeed impinges upon their personal safety and dignity, placing them at risk of assault.(6) For women everywhere, this question of safety and hygiene forces them to restrict fluid intake and hold their bladders in public places and while traveling. They are thus courting the risks of repeated menstrual issues and urinary tract infections.(7,8)

The indirect effects of poor sanitary and living conditions are far reaching, especially in crucial services such as medicine. My own experience during my MD residency, exploring the factors influencing assaults on doctors by patients and caregivers, revealed an extensive and interconnected web of causality in these assaults. Most of my clinician colleagues whom I interviewed, revealed that anger due to a perceived impatience in communication by the doctors played a role in inciting patient parties to lash out physically at doctors. The doctors, however, were overburdened and had no proper facilities for food, rest or sanitation, which caused them to function in a state of perpetual stress and thus blunted their capacity for empathy.(9)

I have witnessed and borne these hardships myself, as a public health doctor working in disaster response and remote field outreaches. As an MD resident specialising in Community Medicine, I have been posted to a rural health centre where the toilet door itself was missing, and performing one’s natural functions was a dangerous gamble against unwelcome intrusions. During vaccination campaigns in urban slums, I have been obliged to use public toilets soiled from floor to ceiling. Imagine the plight of the women living in those slums, who must encounter such horrific sights and smells every day as well as bear the dangers of bacterial contamination in using such facilities. In the wake of the 2005 Mumbai floods, I was posted to numerous disaster relief camps set up in municipal schools and sometimes simply in a travelling van, with no toilets anywhere in sight.(10) My experiences are mirrored in the cries of thousands of medical students and junior doctors who are forced to cope with deplorable sanitation facilities unnecessarily complicating the rigours of their training. (11,12)

I write this essay not just as a medical doctor and preventive medicine specialist, but as a woman who has had to endure the difficulties of unsafe and unhygienic toilets in my academic, professional and personal endeavours. I hope, therefore, to lend my voice and agency to advocate for women’s safety and sanitation needs, and call for ensuring universal access, hygiene, and privacy in this fundamental, indispensable aspect of life. Let us all lend our support to the Swachh Bharat Abhiyan, taking to heart our Honourable Prime Minister’s insight into the inextricable bonds between sanitation and self-respect.(13) Let us be united in seeking emancipation for all girls and women.

References:

1.         Drèze J, Khera R, Somanchi A. Maternity Entitlements in India: Women’s Rights Derailed [Internet]. SocArXiv; 2021 [cited 2023 Sep 27]. Available from: https://osf.io/preprints/socarxiv/v5mc6/

2.         WION [Internet]. [cited 2023 Sep 27]. India: Women’s Reservation bill passed in parliament as Rajya Sabha gives nod with absolute majority. Available from: https://www.wionews.com/india-news/india-womens-reservation-bill-clears-rajya-sabha-with-absolute-majority-638337

3.         CDC. Centers for Disease Control and Prevention. 2022 [cited 2023 Sep 27]. The Need for Toilets and Latrines. Available from: https://www.cdc.gov/healthywater/global/sanitation/toilets.html

4.         Sanitation [Internet]. [cited 2023 Sep 27]. Available from: https://www.who.int/news-room/fact-sheets/detail/sanitation

5.         Pandey D shikha. Feminism in India. 2023 [cited 2023 Sep 27]. Lack Of Sanitation And Hygiene Is A Threat To Girls’ Education. Available from: https://feminisminindia.com/2023/05/01/lack-of-sanitation-and-hygiene-is-a-threat-to-girls-education/

6.         Video row underlines poor conditions at GMCH MARD hostel. The Times of India [Internet]. 2023 Jul 19 [cited 2023 Sep 27]; Available from: https://timesofindia.indiatimes.com/city/nagpur/video-row-underlines-poor-conditions-at-gmch-mard-hostel/articleshow/101907274.cms?from=mdr

7.         Magazine U. Undark Magazine. 2022 [cited 2023 Sep 27]. For Many Indian Women, Lack of Toilet Access Poses Health Risks. Available from: https://undark.org/2022/07/20/for-many-indian-women-lack-of-toilet-access-poses-health-risks/

8.         Hindustan Times [Internet]. 2022 [cited 2023 Sep 27]. Why women do not use washrooms at railway stations. Available from: https://www.hindustantimes.com/cities/mumbai-news/why-women-do-not-use-washrooms-at-railway-stations-101665686463245.html

9.         Assaults on public hospital staff by patients and their relatives: an inquiry [Internet]. Indian Journal of Medical Ethics. [cited 2023 Sep 27]. Available from: https://ijme.in/articles/assaults-on-public-hospital-staff-by-patients-and-their-relatives-an-inquiry/?galley=html

10.       Mukhopadhyay A. Resuscitating Mumbai from sickness, slums and calamities to secure social capital. In: The Lancet, WHO and Global Forum for Health Research:  Young Voices in Health Research 2008 [Internet]. Available from: https://www.researchgate.net/publication/370029448_Lancet_WHO_Young_Voices_in_Health_Research_page_110

11.       Paul S. TheQuint. 2018 [cited 2023 Sep 27]. Bengal’s Top Medical College Has Dirty Toilets & Unlivable Hostels. Available from: https://www.thequint.com/photos/calcutta-medical-college-hospital-student-protests-dirty-hostels

12.       Hindustan Times [Internet]. 2022 [cited 2023 Sep 27]. Deplorable living conditions in govt hostels make life hell for med students. Available from: https://www.hindustantimes.com/cities/mumbai-news/deplorable-living-conditions-in-govt-hostels-make-life-hell-for-med-students-101669488660544.html

13.       Bhaskar SD Sonia. Prime Minister Narendra Modi Says Participation Of Women Has Been Instrumental In Swachh Bharat Abhiyan’s Success [Internet]. NDTV-Dettol Banega Swasth Swachh India. 2018 [cited 2023 Sep 27]. Available from: https://swachhindia.ndtv.com/pm-modi-women-and-swachh-bharat-abhiyan-19960/

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