I was hospitalized with a urinary tract infection (UTI) for the first time in my early teens. It was not a shock to me after the doctor told me what caused it: ‘Not drinking enough water and holding urine’. It was so traumatizing for me to go to the school’s toilet that I avoided going as much as I could. Even after understanding what impact, it had on my health, I didn’t want to use the toilet facilities outside my home. I at times went up to over 10 hours drinking a minimum amount of water or no water at all. I didn’t want to use unhygienic, smelly, and unclean toilets. It took me over ten years, several more visits to the hospitals, sleepless nights with numbness, severe pain, and the threat of kidney failure to finally realize that I need to drink water and use the toilet whenever I need. For the longest time I thought I was the only one suffering from this situation. But during my university when I started interacting with other girls, from different backgrounds, I got to understand that it was the story of every other girl. I finally could share my anxiety and problems caused by UTI with people who could actually understand my situation. Each of these girls had their own ways of dealing with these issues, home remedies, and horrifying experiences of using public toilets.
What is a UTI? Why is this discussion on health and hygiene so important? Holding urine for a long time can cause several health effects: Urinary Tract Infections (UTI), bladder infections (Cystitis), kidney infections (Pyelonephritis), anxiety, fevers, pain at the time of urinating, stomach pain, abdominal pain, swelling of the bladder, and kidney stones.
UTIs are one of the most important causes of morbidity and mortality in developing countries like Bangladesh. They cause health issues for women, but more than that they harm women’s careers, mobility, and freedom. This discussion is as important for women’s empowerment as issues like financial independence or the right to education.
Background
Urinary tract infections (UTIs) are one of the most frequent clinical bacterial infections in women, accounting for nearly 25% of all infections. Around 50–60% of women will develop UTIs in their lifetimes. Recently, a team from the University of Dhaka studied a hospital in Dhaka, where 300 patients came in to test for UTI. For 42%, the sample was found positive. 64% of adult women tested positive for a UTI, compared to 31% of men and children each.
After the birth of Bangladesh, the development work of the country was widely focused on rural areas. Even mass urbanization is a recent situation for the country. Bangladesh has made a lot of progress in the areas of water, sanitation, and hygiene (WASH), bringing down open defecation to almost zero, ridding the water of arsenic, and reducing the mortality rate due to diarrheal diseases. With the new wave of urbanization and modern life, needs have changed. Women, whether rural or urban, are moving for work, mostly far from home. Policymaking, for a very long time, was done by men and is still dominated by men, therefore keeping only men in mind and not women or non-binary people.
There has been a lot of work in the sector of WASH, although no specific goal was set in the Millennium Development Goals (MDGs). After 2015, Sustainable Development Goals (SDGs) came up with specific goals related to WASH, SDG 3 – good health and wellbeing & SDG 6 – clean water and sanitation. Through the research on reaching communities, it became clear that the way to change the hygiene practices in families is through the mothers and the wives. Unfortunately, the policies for women’s health and sanitation facilities focus on women being the leader of the changes in the community, not the wellbeing of the women themselves.
A report by UNICEF pointed out that one of the biggest reasons girls drop out of school is lack of toilets. According to the UNICEF WASH report, in Bangladesh the standard number of toilets in schools has been set as a minimum of one toilet for every 60 students. But in reality, the schools on average have half a toilet, which in many cases is unusable. The Sustainable Development Goals 5 and 10, which are gender equality and reduced inequality, should also focus on the health of women. It is very recently that menstruation has become less taboo, thanks to attention given by social media platforms and pop culture. Yet there is still a taboo around women using sanitation facilities, when often there are no facilities to even use. This has been a big obstacle in their mobility.
Research
To understand the impact of lack of sanitation facilities on women’s health and mobility, I conducted a survey of 200 women who are living, studying, or working in Dhaka, the capital of Bangladesh. First, I wanted to understand their idea of a usable public toilet, which they defined as clean and hygienic. Most of these women had experienced a UTI, had tested for a UTI, or had suffered from dehydration. One of the main causes of UTIs and dehydration is not drinking enough water. and only 34.6% of surveyed women answered that they drank enough water. When asked for an explanation, more than two-thirds of these women said that they didn’t want to use the toilet outside of their home.
When asked, ‘Do you tend to hold your need of using the toilet because of unhygienic washrooms?’, women answered in the following manner:
Many of these women shared their personal stories. One of the first things women check while joining a new workplace is the toilet. A young professional who had been working for 2 years shared that the best thing about her workplace is the toilet facilities. On the other hand, another person shared that her workplace had a common toilet for men and women. For six months, she had to use that toilet and experienced UTIs until she left the job. Women before committing to any plans or work think about the toilet facilities. There are women who are leaving jobs or opportunities because that demands traveling or fields.
One of the participants (Anika, 29) said – ‘If it is a long trip, the first thing that comes to a woman’s mind is how she will deal with the need of urination. The date of travel is decided around the time of her periods, the mode of traveling is also decided depending on the comfort of the toilet facilities. Traveling by train is a very safe and budget-friendly option while going outside of the city, but traveling by bus is preferred by many because the traveler gets toilet breaks. And many prefer going by air with 4 times more ticket price because it takes a short time to fly from one city to another which helps her avoid public toilets.’
Can hygiene and hence good health only be afforded by the people who are financially sound? A woman who can’t afford a plane or good private buses won’t be able to urinate for hours for the lack of hygienic toilets or even toilets at all.
All these things create an immense amount of anxiety and panic in any woman before she decides to leave the house. Many of them have ‘nervous bladder’ which means they get the urge to use the toilet whenever it is available, even if it is not necessary.. It causes a certain kind of insecurity, which in itself creates difficulties in their mobilization. This actually limits women’s mobility in the public sphere as well. One of the participants (Eva, 25) shared – ‘My university has an auditorium which can contain up to 2000 people. It has separate toilet facilities for girls and boys. But it has only one toilet for girls, 2 toilets and 2 urinals for boys. This reflects the representation of authority’s thinking.’
My research also included conversations with a few men regarding their experiences while traveling and using public toilets. Most of them shared that the thought of finding a toilet to use when needed when they are out doesn’t cross their mind. Of course, washrooms and toilets are not clean or hygienic when it comes to men’s facilities but this does not stop them from using the toilets One participant explained (Arif, 27) ‘I do not need to touch any surface to relieve myself’. I do not get anxiety because I know there will be one way or another, if nothing then I can always go to some corner or behind a bush to relieve myself’
The need for sanitation facilities also presents itself in discriminatory train ticket pricing. In my research, 22% of women faced a different ticket price than men for using the public toilet , 66% were not sure and only 12% of women said that they didn’t face any discrimination This discrimination violates basic human rights.
Finally, when asked, do you use Government- run public toilets? the overwhelming majority of respondents said no:
These results prove that local governments need to invest in better public sanitation options.
Conclusion and Policy Implications
According to The World Bank, there are 6 issue areas focusing on gender inequality, two of which are mobility and health/hygiene. These are obstacles for the growth of any woman, especially those who are below the upper class.
There is very little research done on UTIs and their health implications. Gender representation while making policies is very important to break the blindness of the policies. The reality is, women’s development does not only depend on economic empowerment or independence, but also has other dimensions including women’s movement in public spaces. This includes safe public transportation, safe roads, safe workplaces, and hygienic sanitation systems. These issues act as an obstacle in the mobilization of women. By ensuring safe and hygienic toilets in public spaces, we can build a world where women can empower themselves. Apart from that, a country like Bangladesh needs to discuss UTIs and UTI awareness. A community can only be better with the input of one hundred percent of its demography. A country can only benefit from making a livable city for everyone, which starts with ensuring basic human rights.
Women must not lose out on opportunities to work, to study, to travel or to enjoy their lives because policies failed to make the world’s infrastructure women-friendly.