“Safe drinking water and sanitation are indispensable to sustain life and health, and fundamental to the dignity of all.”1United Nations, The Right to Water, 2010.
Everybody goes to the toilet.
Wait—is that really right? It can’t be, can it, when UNICEF says that 1 in 3 people worldwide don’t have access to a safe and usable toilet? So let me change that opening phrase to the shorter, more accurate: everybody “goes.” There is little choice about when to go, and often little choice about where to go, especially if you are a woman or a girl, who, because of social norms, needs greater privacy. What do you do in the absence of even rudimentary facilities?
We’ll start with Sustainable Development Goal (SDG) 6: ensure access to water and sanitation for all. SDG 6 has eight “targets”—that’s UN-speak for how we will know whether or not the world is making progress on the goal. The second target addresses sanitation directly: “By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations.” This target commits the global community to universal access regardless of age, income, ability, or gender; only universal access can be equitable “for all.” In addition, men and women have different sanitation needs. Male sanitation needs can be met in the course of meeting female sanitation needs, but the reverse is not true; therefore, only sanitation programs that are explicitly designed for female needs can be adequate “for all.”
Where sanitation advocacy stands now“A sea-change has occurred in recent years with respect to recognizing sanitation as indispensable for health, dignity, and development.”
Sanitation programs are on the rise, promoted vigorously by health researchers, governments in concert with local communities, and international donors and nonprofits. A sea-change has occurred in recent years with respect to recognizing sanitation as indispensable for health, dignity, and development, because the negative impacts of poor sanitation on diarrheal diseases and long-term malnourishment have been widely recognized. The language of SDG 6 highlights open defecation, or the widespread practice of relieving oneself without a toilet (i.e., in the open). Open defecation is indeed a public health and environmental health hazard, causing both disease and water pollution. Most national and international efforts to promote the use of toilets and to extend access to toilets for the many who are still unserved have emphasized “private” toilets (i.e., one toilet per family), and building toilets in the home (or at least on the premises). A smaller but still significant effort has been spent on school sanitation, because children—especially adolescent girls—find it difficult to stay in school if there are no usable toilets.
All of these efforts have borne fruit; from 1990 to 2015, more than 2 billion people gained access to improved toilet facilities, and open defecation rates dropped significantly in all developing countries. However, it remains the norm for 1 billion people, 90 percent of whom are rural residents, mostly clustered in South Asia and sub-Saharan Africa. Additionally, almost 700 million people use shared facilities (i.e., more than one household to one toilet); until (very) recently, the international water and sanitation community was unwilling to consider such facilities as an acceptable standard of “access” to sanitation.
The current emphasis on eliminating open defecation through expanding access to in-home latrines is absolutely critical for health and dignity. In-home latrines are important for the safety of women and girls, who otherwise may have to walk long distances from home in order to defecate in the fields in the dark. Such a necessity courts risk every day, from stray dogs, stray snakes, and stray men. There is evidence from India that safeguarding the modesty of the household’s young women can be a powerful spur to latrine building.2For empirical evidence and also accounts of government campaigns based on this premise, see Dianne Coffey, Aashish Gupta, Payal Hathi, Dean Spears, Nikhil Srivastav, and Sangita Vyas, “Culture and the Health Transition: Understanding sanitation behavior in rural North India,” International Growth Center Working Paper, April 2015. www.theigc.org. But, we have to ask: Is this enough for sustainable or gender-equal sanitation? Is this enough to meet the human right to sanitation and the goal of “dignity for all”?“Gender equality is a public good; public goods need public infrastructure.” I argue that it is not. Inadequate access to basic sanitation outside the home also prevents the realization of a range of human rights and of gender equality. Gender equality is a public good; public goods need public infrastructure. Furthermore, I argue that sanitation infrastructure that serves all genders equally must be designed and implemented explicitly for the unique needs of women and girls. Sanitation programs for universal access must go well beyond encouraging in-home latrine uptake and discouraging open defecation.
Let us start with the most obvious reason for the inadequacy of in-home toilets as the primary route to universal sanitation. In-home toilets require a home, and globally, over 1.5 billion people are without adequate (or sometimes any) housing. Transient workers, recent migrants, refugees, and pavement dwellers are among the many who may have a roof of sorts, but certainly not a “home” that can feasibly house the smallest of latrines. Even semi-permanent structures, such as brick and mud homes in densely packed urban slums, cannot contain a toilet pit or bowl. If five people share a 300 sq. ft. space, where does the toilet go? As the number of refugees, migrants, and slum dwellers continues to increase, public (or otherwise shared) latrines remain essential for equal access to safe and dignified sanitation.
There is another, possibly less obvious, reason that in-home toilets are only part of the solution for universal sanitation for women and girls. Home toilets are fine if you are at home all day. But women who work in other people’s fields; or who sell vegetables by day or night; or who walk to fetch fuel and water; or who are postal workers or policewomen cannot be home all day. If they live in low-income neighborhoods far away from work, they have to wake up at five o’clock in the morning and take buses and trains into work. Then back they go at the end of the day, possibly getting home to their families, their chores, and their toilets, at seven o’clock at night. In those intervening twelve or so hours, they have to urinate. They need safety and dignity not only for the “long call” of Nature, or defecation, but also for the “short call.”3These terms, or their equivalents, are common euphemisms in several cultures. See Bethany A. Caruso, Robert Dreibelbis, Emily Awino Ogutu, and Richard Rheingans, “If You Build It Will They Come? Factors Influencing Rural Primary Pupils’ Urination and Defecation Practices at School in Western Kenya,” Journal of Water, Sanitation and Hygiene for Development 4, no. 4 (2014).
The lack of clean extra-household facilities in slums, markets, transit hubs, health clinics, government offices, and schools is a problem for all genders. But, it is a particular problem for women and girls (and indeed for transgender individuals). If absolutely necessary, a man can urinate against a wall or behind a tree; this is not considered especially attractive, but it is often not taboo. But women have to cover their bodies in conformity with modesty norms that “require” women not to expose themselves in exactly the way that biology dictates they must when they urinate. Where there are usable toilet blocks, payment arrangements are critical. Women will need more frequent use of public latrines, since they are forced to use them for urination as well as defecation. Thus, pay-per-use toilets with an equal price of access for men and women—a common mode of financing facilities in slums—inadvertently provide an unequal level of service across genders.
It is clean, secure, and affordable access to latrines outside the home that can enable girls’ education, women’s mobility, and women’s livelihoods. Not only do women need more privacy, they need more time in the toilet because they must always sit or squat; witness the much longer lines outside the women’s toilets than outside the men’s, anywhere in the world. They need to urinate more frequently when they are pregnant. They need to feel physically safe when they use outside or public toilets, and they have to use such toilets when they are out and about at school, in the marketplace, or at the workplace. Women who have no usable toilet facilities during the day routinely withhold food and (especially) drink during the day, leading to dehydration, discomfort, fear of incontinence, and—at worst—urinary tract infections. So sanitation programs cannot stop at defecation and disease; they have to take equally seriously the requirements of dignity and safety for daytime urination.“Research from Asia and Africa has shown that poor sanitation keeps girls from school, or interferes with their ability to learn, when they are menstruating.”
I come now to the third call of Nature, what might be termed the “monthly call,” that goes out uniquely to adolescent girls and women. Menstrual hygiene is only now being acknowledged as the critical programmatic gap as the SDG targets and indicators are being finalized. Women need daily toilet visits and privacy for changing during their menstrual period, but menstrual hygiene is so “taboo” that it has routinely fallen through the cracks of national and international sanitation promotions. A small and sobering body of research now deals with the causes and consequences of poor menstrual hygiene management, especially in schools.4→Shannon A. McMahon, Peter J. Winch, Bethany A. Caruso, Alfredo F. Obure, Emily A. Ogutu, Imelda A. Ochari, and Richard D. Rheingans, “‘The Girl with Her Period Is the One to Hang Her Head: Reflections on Menstrual Management among Schoolgirls in Rural Kenya,” BMC International Health and Human Rights 11, no. 1 (2011).
→Joshua V. Garn, Leslie E. Greene, Robert Dreibelbis, Shadi Saboori, Richard D. Rheingans, and Matthew C. Freeman, “A Cluster-Randomized Trial Assessing the Impact of School Water, Sanitation and Hygiene Improvements on Pupil Enrolment and Gender Parity in Enrolment,” Journal of Water, Sanitation and Hygiene for Development 3, no. 4 (2013). Research from Asia and Africa has shown that poor sanitation keeps girls from school, or interferes with their ability to learn, when they are menstruating. High levels of discomfort, fear, bewilderment, and shame associated with menstruation, coupled with the inability to manage menstrual hygiene discreetly, highlight the urgent need for girl-friendly sanitation facilities in schools. Equal access to education for all genders is intimately tied to this mundane facility.
The argument here is that dignity rather than diarrhea belongs at the heart of sanitation programs. In accordance with the Sustainable Development Goals, in which access to basic sanitation is both necessary and a right, I suggest that sanitation needs are greatest, and impacts have the most potential for good (for health, opportunity, and dignity), among those who are most marginalized, including low-income women. In particular, sanitation in publicly shared spaces—in slums and schools and streets—must be pulled out of its current neglect in public policy circles to become a cornerstone of sustainable development planning.
This conclusion, however, has met with considerable opposition in municipal planning offices whenever and wherever I have raised it. It’s too much, goes the counterargument. It’s difficult enough to set aside funds for public or community toilets; “Now you also want these toilets to be good for ladies. You are asking for too much extra—extra space, extra water, extra money.” In low-income cities in low-income countries, I have some sympathy for this objection. But this perspective begs the question: why is gender-equal sanitation that meets all three sanitation needs of women and girls “extra”? What is this insurmountable “extra”?
Prioritizing women’s sanitation needs
I can only conclude that it is because the de facto body that sanitation programs are still being designed for is the male body. I come to this conclusion despite the rather vague (and coy) gesturing in SDG 6 towards “special attention to the needs of women and girls.” Behind every target of sustainable development, there is an implicitly imagined body, a sort of “prototype” body. The push toward in-home latrines is focused on ending open defecation, as though defecation is the only real sanitation need. But men and women, and girls and boys, have different sanitation needs. Investments in sanitation, therefore, have to be designed and implemented with their diverse bodily needs, and the social norms and expectations that surround them, at the center.5Of course, gender equality in sanitation cannot be achieved by facilities and sanitation programs alone: changing social norms and expectations is at least as important. This paper focuses on safe and accessible sanitation facilities, recognizing that safe sanitation is a human right, whatever the prevailing norms may be. They must become more explicit about the prototype body that they are (primarily) designed for. If that body (implicitly) remains male, then women’s needs indeed appear as “extra.”“If our goal is universal access with gender equality, then this prototype body should belong to a low-income woman without a toilet in her home.”
Without crossing into reductionist naturalizations, and without falling into the pernicious trap of one’s-body-is-one’s-destiny, we have to recognize that the human body is the entity that houses human rights. We must recognize the “irreducible specificity of women’s bodies.”6Bloomington, IN: Indiana University Press, 1994More Info → What does this recognition mean for sustainable development and for sanitation? It means that sanitation programs and sanitation policies must become explicit about the prototype body that they and their indicators are written for. If our goal is universal access with gender equality, then this prototype body should belong to a low-income woman without a toilet in her home. That’s a body that will need to “go” several times a day, must always sit or squat to use the toilet, must be safe from assault on her way to and from the facilities, should not be exposed while using the facilities, and will bleed for four days a month for forty years, except if she is pregnant or dies young. Gender equality means designing sanitation for that body.
UN Human Development Report 2006. Beyond Scarcity: Power, Poverty and the Global Water Crisis. United Nations Development Programme.
Zachary Burt, Kara Nelson, and Isha Ray. “Towards Gender Equality through Sanitation Access.” UN Women Discussion Paper, 2016. http://www.unwomen.org/en/digital-library/publications/2016/3/towards-gender-equality-through-sanitation-access.
→Joshua V. Garn, Leslie E. Greene, Robert Dreibelbis, Shadi Saboori, Richard D. Rheingans, and Matthew C. Freeman, “A Cluster-Randomized Trial Assessing the Impact of School Water, Sanitation and Hygiene Improvements on Pupil Enrolment and Gender Parity in Enrolment,” Journal of Water, Sanitation and Hygiene for Development 3, no. 4 (2013).