Environmental Health
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Strategies to combat menstrual myths and protect women’s health in India
Scope of the problem
Up until adolescence, girls and boys in India attain roughly the same levels of education, health, and workforce participation outcomes. However, upon puberty, girls begin to diverge from boys and see increasing limitations in their social mobility and personal agency. Though there are over 355 million menstruating women in India, insufficient menstrual hygiene management is a significant barrier to women’s experiences. Access to clean facilities, menstrual products, and reproductive health resources categorize this as a health issue, but its implications spread to educational attainment, financial stability, social mobility, and individual autonomy.
Menstruation is still a taboo topic in many spheres of women’s lives in India. In some areas, 71% of Indian girls report not knowing about menstruation prior to their first cycle. Young women in Rajasthan report feeling shock, fear, anxiety, and guilt regarding their cycles, which emphasizes the heavy psychological toll a lack of education and awareness leads to. Financially, approximately 70% of women in India cannot afford sanitary products and 23% of young girls drop out of school when they reach puberty due to lack of clean, private toilets. In fact, 40% of government schools lack a functioning toilet, and another 40% lack a private women’s restroom. At home, millions of women are barred from entering the kitchen, interacting with family members, or praying during menstruation. Some essentially banish their young women to menstruation huts called gaokors[footnoteRef:1]. [1: https://www.theguardian.com/global-development/2015/dec/22/india-menstruation-periods-gaokor-women-isolated]
Origins of the taboo on menstruation
The taboo against discussing menstruation can be traced to cultural and religious roots wherein women are considered impure during their cycles, but women across the country are taking to the streets to break the silence and normalize menstruation. What strategies might be effective in reducing this taboo? Because these taboos affect health, educational and financial opportunities, and originate from culture, religion, lack of education and infrastructure, the solutions must be just as holistic. Some examples from the research are: cleaner toilets in schools, court cases supporting women’s rights, education for adolescent girls and their school teachers, and low-cost sanitary napkins[footnoteRef:2]. As I continue this research, I am interested in finding early legislation that either supports or denies menstruation resources to women. [2: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408698/]
Current and possible interventions
As the amount and level of women in the Indian workforce grows, from 28.5% in 1994 to 43% in 2012[footnoteRef:3], women gain more financial independence and more of a political voice. Increasingly, organizations like the Bill and Melinda Gates Foundation, governments, donors, and private companies have taken in interest in these issues and four trends of interventions have arisen. They are: Education, Menstrual Hygiene Management (MHM) Products, Sanitation, and Policy. These interventions fall into the operational and political levels of political economy analysis. None of them fall into the technical bracket as widespread academia and technical know-how already exists on how to intervene effectively and relatively affordably. For example, a hollow outhouse of sorts can be built for only Rs. 5500, while a sanitary facility for an entire school can be added for roughly Rs. 50,000 (USD $715)[footnoteRef:4]. Thus, the implementation of these falls more into an operational context. The only area that may require technical innovation is the creation of hyper-low-cost sanitary products. [3: https://www.rand.org/blog/2014/08/womens-menstrual-hygiene-in-india-the-health-and-environmental.html] [4: http://www.thealternative.in/business/10-toilet-designs-for-rural-india/]
Both education and MHM policy require political will and influence which has yet to be triggered. In regions where a curriculum has been created, and the operational hurdles have been passed, states often lack the political will to implement teacher trainings or even allow NGOs to lead workshops. Conversely, provision of Menstrual Hygiene products and implementation of sanitation initiatives is more of an operational issue. Even though low-cost pads have been innovated, the taboo against them and the lack of selling points leaves women without access.
Building toilets is one intervention from the ones listed above that has actually seen bounds of improvement during the past decade majorly due to reasons other than women’s hygiene[footnoteRef:5]. The percentage of households with access to a toilet grew from under 40% in 2014 to 70% on average by 2017 due to Prime Minister Modi’s Clean India Mission which funds the construction of 111,100,000 toilets (USD$30 billion) in rural areas. To date, over 92 million toilets have been built and over 550 thousand villages have been ruled open defecation-free[footnoteRef:6]. An important point to note in these developments is that the frame has not been one of women’s access to sanitary toilets or education specifically, rather one of uplifting the entire nation to an international standard. The framing of these interventions is clearly an important one moving forward, and a strategy I will discuss in a later section. In the next stage of this project, I would be interested in mapping girls education statistics onto the new toilet statistics to see where the improvements correlate and where opportunities still exist. Another important note is the issue of monitoring and evaluation—there is yet to be independent verification of the numbers mentioned above[footnoteRef:7]. [5: https://brilliantmaps.com/indian-toilets/] [6: http://swachhbharatmission.gov.in/sbmcms/index.htm] [7: https://brilliantmaps.com/indian-toilets/]
Figure 1 Brilliantmaps.com
While toilets/sanitary interventions are framed as a general public health and wellness need and help MHM as a side-effect, the Education and Product spheres of intervention are indeed framed MHM issues and have become focuses of NGO and private interventions that I will discuss within the Kingdon and Health Pyramid frameworks.
Researchers understand what interventions are effective in reducing taboos and protecting women’s health, but what gets these solutions on the table? Where does the political will come from to build clean toilets in India’s poorest towns? How will the officials in a corrupt political environment with religiously-backed campaigns support MHM initiatives? What elements compelled India’s Supreme Court to rule in favor of women?
Generally, there does not appear to be a particular trend regarding which Indian states are more successful at policy interventions other than a case-by-case basis. However, gender parity is be an important proxy for menstrual hygiene access. McKinsey Global Institute categorized Mizoram, Kerala, Meghalaya, Goa, and Sikkam as the five most equitable regions while Uttar Pradesh, Bihar, and Rajasthan are considered the most unequal. In this memo, I will begin examining a couple of these regions based on public health frameworks.
Where is Menstrual Hygeine on the Agenda: Maharashtra & Kerala?
Using Kingdon’s stream framework, we can examine where in the agenda-setting process menstrual hygiene falls[footnoteRef:8]. Applying Kingdon’s framework precisely becomes difficult when the particular topic of menstrual hygiene has not reached the national agenda and there is significant variation from state to state and even within a single state. It becomes important then to choose a specific local case and hash it out step by step to glean insight for the national level. [8: Howlett et al Ch 4]
For now, I will discuss the examples of Maharashtra, considered one of the worse-off regions with over 223 menstrual huts. The ethnic groups where this is most prominent are the Gond and Madiya[footnoteRef:9]. Here, most of the women do not enjoy the practice of staying in the huts but feel they must maintain their traditions and customs. Most of these huts do not contain kitchens, clean toilets, or beds, so some actors have recognized the practice as a problem, placing menstrual hygiene in the “problem stream.” Another important part of placing menstrual hygiene in the problem stream is the presence of social media. The #periodforchange and #happytobleed campaigns grew out of public and celebrity reactions to the stigma around menstruation[footnoteRef:10]. [9: https://www.theguardian.com/global-development/2015/dec/22/india-menstruation-periods-gaokor-women-isolated] [10: https://www.bbc.com/news/world-asia-india-34900825]
Within the policy stream, NGOs, researchers, private actors are actively researching solutions and beginning to implement them autonomously where they can. In one village, Sitatola, the village’s Panchayat, a local self-governing body, decided to bring the gaokars closer to the village and put beds in them. A Maharashtrian organization, Lok Biradari Prakalp, has created a school to teach 350 girls about menstruation. A local NGO, Sparsh, actively evaluates and monitors the gaokors and has run 12 workshops in remote villages. One representative tellingly says, “Because it’s a sensitive topic, we try to educate them about health and hygiene without mentioning gaokor.” This comment speaks to the issue of changing the context while maintaining cultural sensitivity, which I will discuss in the next section.
Regarding the political stream, governments are experiencing slight pressure from organizations like the National Human Rights Commission, which instructed the Maharashtran government to end the use of gaokors. Yet, the state government as a whole has not taken any action on the matter. In fact, one of the only regions where the state has taken a stance on menstruation is Kerala. In September 2018, the Supreme Court lifted a ban that prevented women ages 10 to 50 from entering a Hindu temple in Kerala. In January 2019, when two women actually entered the temple, it triggered protests and riots throughout the region. This court case could be labeled the focusing event within the four-month “routinized political window” created when the Supreme Court is in session every year.
One issue with the Kingdon framework is that it is primary helpful to label events and “streams” retroactively and does not appear to yield much predictive power. For example, it will be interesting to examine whether the protests sparked because of the Supreme Court decision will becoming the focusing events or “random problem windows” through which activists will move forward on the issues of menstrual awareness. But it will be difficult to call it a trigger or focusing event until some action actually does take place. That being said, a recent documentary, Period. End of Story was published to bring light to the issue following the January protests[footnoteRef:11]. Media attention further categorizes this as a focusing event. Regarding the building of toilets as discussed earlier, the public health framing of the need for toilets may also have created a spillover problem window which brought attention to MHM issues. But again, it is hardly possible to preemptively label events as problem windows. Political windows, on the other hand, are much more useful as they are more predictable and provide avenues for policy entrepreneurs. [11: https://www.economist.com/prospero/2019/01/22/a-new-documentary-addresses-the-stigma-of-menstruation-in-india]
Framing is another essential component in understanding why India’s highest court decided to rule against the centuries-old custom in a country where many women are still banished to menstruation huts. The courts cited their decision as necessary to uphold the rights to equality of worship[footnoteRef:12]. In the judgement, Justice Dipak Misra said, “Patriarchy in religion cannot be permitted to trump over element of pure devotion borne out of faith and the freedom to practice and profess one’s religion.” This frame and the argument surrounding this case focused on religious freedoms rather than menstrual rights and women’s rights in general. [12: https://www.reuters.com/article/us-india-court-temple-idUSKCN1M80MK]
The issue of framing, for toilets, court cases, and even education in villages with menstruation huts is important in changing the context surrounding MHM in India.
Friedan’s Health Pyramid: changing the context for menstrual health
Frieden’s health impact pyramid is a useful lens through which to examine menstrual health issues in India. I’ll briefly examine interventions that fall into each level of the pyramid. At the bottom socioeconomic factors level, WASH initiatives (“sanitary interventions”) are the most effective and far-reaching. Access to clean water and sanitary facilities to maintain a hygienic environment will go a long way to providing women access to education, public areas, employment etc. that would have otherwise been inaccessible.
The next level of intervention, Changing the Context is more MHM-specific and requires targeted efforts. For the issue of menstrual health, changing the context means normalizing the issue of menstruation for the Indian populace and creating an environment where women have the ability to stand up for their rights and discuss their bodies. This is a tall order, but it can be broken down into practical interventions. A broad example is building private girls’ toilets in schools—an intervention that would make young girls’ default decision, going to school, both feasible and healthy during menstruation. While building toilets somewhat also falls into the socioeconomic factors level, it also applies to changing the context, specifically in schools.
Another effective way to change the context, which NGOs and private corporate donors are working on is building access to affordable MHM products. Currently, over 70% of Indian women cannot afford access to products like sanitary napkins. Therefore, their default decisions are to use rags to absorb blood and reuse them, often without sufficient cleaning, which is a health hazard to the women and those around them. If they were accessible, cheap and clean pads whether reusable cloth or disposable or menstrual cups where culturally acceptable, would become women’s default choices. Producing such pads cheaply and selling them in local markets in unassuming packaging even in rural areas would be a good first step.
Access to menstrual education and awareness for both girls in and out of school is also an important part of changing context—if girls knew at an early age how their bodies were going to change and how to practically deal with changes, the trauma and social stigmas would, by exposure within a few generations, cease. Unfortunately, government has volleyed this intervention to NGO initiatives due to a lack of political will and teacher willingness.
Changing the context in the most rural areas of India, where indigenous populations like the Gond and Madiya live will probably be the most challenging. Already, these groups are marginalized and lack resources, which adds another barrier. Firstly, there is little trust between these tribes and a national government they believe is trying to steal their land[footnoteRef:13]. In their situation, it will be particularly important for NGOs to work with local Panchayat and tribal leaders to come up with innovative solutions perhaps beginning with teaching women how to practically manage their periods and slowly moving toward further MHM interventions. [13: https://www.downtoearth.org.in/news/community-forest-rights/gond-tribals-madhya-pradesh-government-fight-for-4000-hectares-of-land-58397]
The next level, long-lasting protective interventions in for menstrual health come in the form of policy decisions like the Supreme Court case in Kerala. This is essentially a long-lasting protection of menstruating women’s rights if not their health directly. Another example would be regular access to a women’s health nurse or doctor, something rural India struggles with—only 3% of India’s doctors live and work in rural areas[footnoteRef:14]. One solution that has been proposed is a menstrual leave policy where women can leave work due to their periods. Western feminists have criticized this intervention as a way to separate women from the workforce and allow discrimination. Others say it allows women to take a break during a time that is strenuous on their bodies, similarly to how a pregnancy might be treated. Nonetheless, it provides a possible solution, which locals ought to weigh in on to make a decision. [14: https://www.bmj.com/content/351/bmj.h5195/rapid-responses]
Finally, in the clinical interventions and counseling and education route, all roads point to the wealthy. India certainly has the facilities to deal with clinical interventions in urban areas, but for rural Indian women, access to an OB GYN is significantly out of reach. Over time, these interventions should also become a priority.
Research Design
Moving forward, I would like to continue to build an overview of India’s 29 states levels of access to menstrual rights in each. A region/town with plenty of clean toilets, access to cheap sanitary napkins, open temples etc will be ranked high, while a region/town with a dearth of these elements will be ranked low.
I will focus on the regions with the highest reported gender parity, Mizoram, Kerala, Meghalaya, Goa, and Sikkam, to begin looking at successful interventions in those areas and see how they originated and developed. My hunch is that framing has been an essential part of creating broad interventions to support women. From all the articles I read, specifically those about the broadest interventions, menstruation was rarely if ever mentioned while general public health, international standards, or educational attainment frames were much more common.
I would like to reach out to some of the NGOs involved in creating interventions, like Sparsh and WASH India to access some of their reports and stories of creating a political shift. Hopefully then I’ll be able to understand what the political factors were that helped get some of these interventions on the table. Was there some sort of trigger such as a protest or death? Was it a question of funding? Did the religious community have a change of heart? One question I have not discussed in depth yet is the role of the religious communities, and how Christian, Muslim, and Hindu religious communities interact with menstrual health interventions.
Ultimately, I would like to examine the political process used to establish some of the effective interventions across India and figure out how they could be replicated in other regions of the country, especially when the government takes responsibility rather than passing it to NGOs. The broad question I would like to answer is “In what situations do Indian government entities (local, regional, or national) effectively intervene for women’s menstrual health and how can such interventions be replicated across the country?”
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