Women and Toilets. A Tale of Two Worlds.

By: Ranit Mishori and Tanvi Nagpal

The scene at the Boston Ballet the other day was not unusual: a long line of women waiting to use the bathroom. Surprisingly, and with the help of a wonderful bathroom attendant who used a microphone to call out available stalls by number, the line moved very quickly. While the efficiency was noteworthy, nothing else about the experience was particularly exceptional. The bathroom was clean, private, had soap and running water. A machine to dispense menstrual products was attached to the wall. Small containers for used hygiene products were handily mounted near the toiler paper (accompanied by big signs plastered on the door pleading with patrons not to throw those products in the toilet). Women went in, attended to their business, washed and dried their hands (hopefully!), and were out.

This is routine for millions of American women. True, many of us complain about cleanliness at times, others about the long lines, and occasionally about running out of toilet paper

But for women and girls living in the developing world, the story is very different.

In rural Ghana when a young girl turns 12, her school life changes forever. Every month she will spend a week in fear of bleeding through her underwear. She will hide her head in shame as she runs to the small, dirty toilet behind the school. There will be no place for her to wash her hands, or dispose of materials she uses to collect menstrual blood, and she will likely go home before the school day ends.

Her cousin, living in a more urban setting, will wake up and line up at the public toilet before she heads to school. Into the pit in the toilet will go the newspaper she used to clean herself and the rags from last night.

Whether you call it a bathroom, a toilet, a washroom, a potty, a loo or a WC.... can you imagine not having one in your home? Or at work? Or at school?

Today (November 19th) is world toilet day, a day designated by the United Nations in 2010 to recognize the issue of safe sanitation and access to clean water.

The statistics are staggering: around the world today 2.4 billion people lack access to basic toilets. That's 1 in 3 people. Hundreds of millions will use toilets that we would never dare to enter. More than a billion people will defecate in the open. According to UNICEF, more than half of the schools in the developing world lack private toilets.

While it is true that everyone - men, women, boys and girls, the elderly and the very young -- is affected by poor sanitary conditions and infrastructure, women and girls are affected the most: it's about our health, our dignity and our safety. It is also about our education and economic prospects. It is about basic human rights.

The indignity of a missing or dysfunctional toilet has health and personal safety consequences for girls and women, especially during their periods. More than 800 million women and girls between the ages of 15-49 are menstruating on any given day.

Millions of those don't have access to good sanitary products, nowhere to dispose those products or wash themselves, coupled with very strong cultural taboos surrounding menstruation which prevent many from discussing the issue, or raising concerns publicly about having to use bathrooms more frequently during their period, or even just about having access to private bathrooms. In fact, women and girls who have no access to bathroom facilities spend 97 billion hours each year finding a place to go.

This double, triple whammy, or quadruple whammy, often leads to missing school days, missing work days, being at risk for sexual violence and being more susceptible to infections.

Openly discussing toilets or bodily functions are hard enough in many cultures. But menstruation is in a class by itself. Privacy, shame, cultural prohibitions and perceptions of impurity make conversations about menstruation taboo, hushed and limited to the underfunded offices of local water and health departments. One survey conducted in India, showed that an astonishing 70 percent of girls had no idea what was happening to them when they first got their period.

Poverty and inequality push the priorities of young girls off their parents' radars and budgets. The working urban poor may actually be able to buy some sanitary products in local stores but this is not the case for the rural poor. Over the years many small NGOs and social entrepreneurs have tried to bring down the cost of sanitary towels or pads by using local materials and labor but none of these ventures has gone to scale in any effective way.

A few years ago the Government of Kenya decided to distribute pads to all primary schools in Kenya to ensure that girls would not miss school when they had their period. This intervention, while noteworthy, would have to be accompanied by the provision of cleaning material and greater attention to maintaining the toilets that girls could use. Sadly, most public schools in the developing world are still a long way from providing clean, safe toilets, let alone adequate cleaning materials, pads and soap for hygiene.

All people in the world deserve to have access to clean toilets. On World Toilet day it's critical to remember that just building new toilets has never ensured that they will be clean, safe and used. For young girls and women in particular, a clean and safe toilet means personal security, better health, educational and economic opportunities, and - as importantly - dignity.

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Tanvi Nagpal is Associate Director and Practitioner in Residence, International Development Program, School of Advanced International Studies, Johns Hopkins University. Her research focuses on improving water and sanitation service delivery for the poor in developing countries.

Ranit Mishori, is a professor of family medicine at the Georgetown University School of Medicine, and director of global health initiatives in the department of family medicine whose expertise is in women's health, health disparities and human rights.