Inadequate sanitation poses significant global risks, affecting over four billion people. Insufficient access to proper facilities leads to social, psychological, and physical threats, contributing to 6.3% of global deaths. India, with one billion residents, grapples with open defecation, affecting half the population. The Swachh Bharat Mission reduced open defecation but challenges persist, especially in rural areas lacking funds for toilets. International initiatives like UNICEF's WASH campaign made strides, yet financial gaps persist for rural and urban sanitation projects. Incomplete infrastructure projects and poor maintenance exacerbate open defecation, impacting vulnerable groups.

This paper by Wren Vogel et al ‘Gender and sanitation: Women’s experiences in rural regions and urban slums in India’ delves into India's sanitation challenges, emphasising gender-related issues. It advocates for increased discourse on remediating the sanitation issues that millions face in developing countries and encouraging a re-evaluation of the apportionment of funds from the private sector by discussing the events that have led to the state of sanitation within rural areas and urban slums of India.

This evaluation and application of sanitation insecurity focuses on the problems associated with poor sanitation within the physical environment, the socio-cultural environment, and the lack of education, and how each relates to gender.

Sanitation

Sanitation research initially focused on pathogen exposure and infectious diseases. Viewing sanitation as a human rights issue emphasises governmental frameworks over physical solutions, asserting sanitation as an inherent right. In India, rural and urban areas face fragmented sanitation issues influenced by economic class, location, and gender.

"Toilet insecurity" denotes unavailability of operable toilets, with 55% globally lacking access to improved sanitation. Ownership doesn't guarantee use; reasons for open defecation include preference, non-functional toilets, inconvenience, privacy issues, and cultural factors. Sanitation insecurity encompasses uncertain access to socio-cultural and physical environments that respect sanitation needs, especially affecting women. Inadequate representation hampers decision-making, limiting women's agency in sanitation discourse.

Gender and sanitation

Gender discrimination in scientific and health journals has historically led to unequal representation, perpetuating an androcentric view in research. Recognising institutionalised patriarchal influence, efforts to address sanitation insecurity emphasise that men and women have different experiences. Approaching this issue from an androcentric perspective would disproportionately affect women.

Historically, menstrual health has been neglected, focusing on sexual and reproductive health within traditional gender roles. Women, more than men, suffer the consequences of inadequate sanitation, described as an affliction of the vulnerable. In India, the world's most dangerous country for women, misogyny is cultivated through limited educational opportunities, gender role constraints, and the misrepresentation of menstruation.

Sanitation insecurity, affecting women in hygienic maintenance and defecation methods, must be contextualised across rural, urban slum, and inner urban areas of India to fully comprehend its gendered impact. Addressing menstrual health is crucial in tackling the broader issue of inadequate sanitation.

Menstrual hygiene management

Menstrual hygiene management is a global public health and social justice issue, shaped by cultural perceptions and economic constraints. The interpretation of normal menstruation varies worldwide, influencing stigmas and beliefs. Menstrual hygiene management involves accessibility to menstrual products, accurate information, and safe, hygienic facilities, impacting overall health.

In India, where diverse cultural and economic factors exist, menstrual hygiene management experiences differ between inner urban, urban slum, and rural areas. Affordability and availability of menstrual products pose challenges, especially for the 800 million people living on less than two USD per day. Menstrual hygiene management, encompassing sanitation, health, and human rights, requires a nuanced understanding through examining women's lived experiences in various regions.

Assessment of sanitation and menstrual hygiene management

In rapidly growing megacities like Mumbai, Delhi, and Kolkata, the escalating population density strains sanitation services and amplifies the demand for adequate facilities. This surge in urbanisation often neglects environmental degradation and socio-economic inequality, exacerbating the gap in sanitation between the urban poor and non-poor. A stark contrast emerges, with nearly all urban non-poor enjoying access to proper sanitation services, while less than half of the urban poor have equal privileges.

The dire environmental conditions in urban slums further compound the sanitation crisis. Inadequate wastewater treatment facilities lead to the contamination of surface water sources, causing severe health problems such as diarrhoea. Shockingly, a staggering 70% of surface water sources in India are reported to be polluted, rendering them unfit for consumption. The repercussions of this sanitation insecurity spiral into a cycle of economic, health, and social problems that persist unless meaningful improvements are made.

The report illustrates the cascade of events causing poor sanitation, emphasising the interconnectedness of economic, health, and social challenges perpetuated by inadequate sanitation. Women, children, and individuals with physical disabilities are particularly vulnerable, and their needs must be at the forefront when devising sanitation improvements.

In the context of slums, characterised by dilapidated housing and insufficient infrastructure, slum-dwellers grapple with unhygienic living conditions. UNICEF and the WHO categorise identified slums as compact areas housing at least 300 people, lacking adequate infrastructure, and devoid of sanitary or drinking water facilities. Unfortunately, decision-making bodies often harbour an anti-poor bias, prioritising formal residential areas over slums.

Toilet block construction, intended to address sanitation issues in slums, often falls short due to inadequate maintenance by municipal corporations. The resulting unhygienic conditions lead to frustration among slum residents, and many women opt for open defecation rather than using poorly maintained toilets, leaving them in a more vulnerable position. The lack of drainage in these constructions allows faecal matter to enter streets, contaminating water sources and soil. The consequences are dire, contributing to ailments such as diarrhoea, trachoma, intestinal worms, and salmonella. In 2018, contaminated water claimed seven lives daily in India, with over 35,000 people diagnosed with water-borne diseases.

The challenges persist due to bureaucratic hurdles within municipal corporations and a lack of ownership at the local government level. Despite efforts to construct toilet blocks, these facilities often face severe sanitary and mechanical issues within a short span, emphasising the need for sustained maintenance and oversight.

The management of menstrual hygiene in slums adds another layer of complexity. Overcrowded living conditions increase the likelihood of illness and sexual violence during menstruation. Women in slums often resort to using old cloths as makeshift pads due to their affordability and availability, with nearly 70% unable to afford commercial sanitary pads. The reuse of old clothes, however, raises hygiene concerns, contributing to an increased susceptibility to urinary and reproductive tract infections, school dropouts, and work absenteeism.

In rural areas, where over half of the global population resides, unimproved sanitation remains pervasive. Government initiatives have focused on building toilets, resulting in the construction of 90 million household toilets. However, this approach often neglects the ingrained social habits and cultural stigmas surrounding sanitation and menstruation, hindering effective usage.

The menstrual hygiene challenges in rural areas are exacerbated by limited access to resources, with 90% of women relying on reused clothing items as sanitary pads. The lack of education and prevalent social constraints create a non-inclusive environment, particularly affecting young girls who navigate menarche alone due to societal taboos. Correlations among toilet availability, poverty, and rural population percentages underscore the critical need for comprehensive sanitation infrastructure and education to support women's health and dignity, especially in low- and middle-income countries.

Conclusion and recommendations

This paper provides a comprehensive examination of sanitation insecurity and menstrual hygiene management (MHM) in urban slums and rural regions of India. It emphasises the multifaceted challenges faced by both men and women due to unsanitary living conditions, particularly focusing on the unique struggles women encounter in managing menstruation amid inadequate water supply and unhygienic environments.

The study rejects the notion that sanitation insecurity is merely a symptom of poverty; rather, it is identified as a barrier hindering poverty reduction and overall development. While acknowledging progress in sanitation and health in India, the paper underscores the need for continued efforts, including dispelling misconceptions through enhanced education for both genders. Proper education on menstruation for males is highlighted as a means to empower women socially and educationally, enabling them to make informed decisions about sanitation and health.

The paper advocates for a holistic approach to assessing sanitation using the definition of sanitation insecurity, considering gendered aspects and dismantling false information perpetuated by cultural beliefs. Recognising the socially induced origin of the issue, the paper calls for timely improvements to prevent irreversible damage to India's physical environment amid a growing population.

The conclusion emphasises the urgency of addressing social stigmas and taboos surrounding menstruation, foreseeing the dissolution of these barriers as understanding and attention to the issue rise. There is a need for sustained research and action to improve sanitation and menstrual hygiene management globally, suggesting that the sanitation insecurity measure could serve as a framework for examining other countries. The holistic perspective provided by this framework encompasses not only the availability of sanitary facilities but also considers the impact of gender, social structures, community awareness, and culture on sanitation quality within a given area.

The full paper can be accessed here