When I finished photographing for my exhibition in a village near Jalalabad, the sun was already in the middle of the sky. It was late May. Northern India’s summer was in full swing, with temperatures reaching 48 degrees Celsius. We left Lucknow early in the morning so that we could get to our destination on time. My travel partner was a young woman in her mid-twenties who worked for the organization partner of the exhibition. The village was approximately 200 kilometers from Lucknow, near Jalalabad. We left immediately after finishing the shoot to catch our evening flight back to Delhi from Lucknow. To combat the dehydration caused by the scorching heat, we kept drinking water in between. Unfortunately, it was slowly and gradually filling the urinary bladder. I asked the chauffeur to pull over near a roadside public toilet on Aligarh-Kanpur Road so I could relieve the pressure in my lower abdomen. He pulled over in front of a gas station, where I discovered three open urinals under the sky.
The urinals smelled strongly of ammonia and didn’t have water, even though the option was there. I managed to void as a privileged Indian male, and with a much-relieved mental and physical state, I returned to the car to embark. As I was about to board, the young lady inquired, “Have you found a toilet for us? I, too, am under duress.” At that moment, I felt as if I had committed a crime in my life. I was overcome with a sense of guilt I had never felt before. I asked the gas station’s employees, but there were none. On the entire expressway, we couldn’t find a single functional toilet that could be used by women. The few options available in roadside restaurants, or dhabas, were completely unsuitable for consumption. She sat beside a guilty soul for the next three and a half hours as she traveled. She was clearly in pain in her abdomen, as evidenced by her expression and body language.
Holding urine for an extended period of time, as my traveling companion did, allows bacteria to multiply within the urinary tract, resulting in cystitis, the most common lower urinary tract infection (UTI) other than pyelonephritis. To help flush bacteria from the bladder, it is advised and encouraged to drink plenty of fluids and urinate frequently. Unfortunately, advice is insufficient until a solution is found.
UTI is the most common bacterial infection in Indian women, and the main cause is Escherichia coli. An estimated 50% of women will have at least one episode of UTI during their lifetime, with 20% to 40% having recurring episodes. It is also one of the most common medical issues that can arise during pregnancy. With an estimated 150 million cases per year worldwide, it remains a major public health problem in terms of morbidity and financial cost, costing the global economy more than US$6 billion. The introduction of antimicrobial therapy has made a significant contribution to the management of UTIs. In almost all cases of community-acquired UTI, empirical antimicrobial treatment is started before the laboratory results of urine culture are available; as a result, resistance in uropathogens may increase due to frequent antimicrobial misuse.
India has recently become a global discussion point on three major issues.
First and foremost, women’s empowerment. According to the national policy, “the Constitution not only grants equality to women, but also empowers the state to implement positive discrimination in favor of women.” According to Section 6.8 of the policy, “Special attention will be paid to the needs of women in the provision of safe drinking water, sewage disposal, toilet facilities, and sanitation within easy reach of households, particularly in rural areas and urban slums.”
Second, between 2014 and 2019, the government provided a subsidy of approximately US$27 million for the construction of nearly 110 million toilets in rural India. To combat open defecation, the campaign has been promoted and advertised.
Finally, there is the issue of antimicrobial resistance in India. According to the World Health Organization, “Antimicrobial resistance (AMR) is causing’superbugs,’ which make treating basic infections difficult (and in some cases impossible). And, while resistance in microorganisms is a continuous phenomenon, its amplification and spread are caused by one factor: human behavior. […] Southeast Asia is most likely the world’s most vulnerable region. AMR not only affects the health and well-being of people in Southeast Asia, but it also has implications for public health and well-being in general.”
Women are now venturing outside their homes, both in urban and rural areas. I’ve seen female frontline workers, who travel daily from towns to remote villages, holding their urine for an extended period of time. As a result, toilet facilities and sanitation should be available not only within easy reach of households, but also along the country’s 1,42,126 kilometers of highways. The word equality probably connotes that women’s anatomy and physiology are equal to those of men, and that women, like men, can urinate in public or in soiled urinals. Finally, in a health-burdened country where 67.78% of total health expenditure is paid out of pocket and 7% of Indians fall below the poverty line solely due to health-related debt, the emphasis should be on preventing the common burden of bacterial infectious diseases like UTI rather than emphasizing expenditures on treatment protocols. The recurrence of UTI results in the forced repetition of antibiotics, most of which are irrational choices, which becomes a recurring financial burden for families, and often leads to the purchase of irrelevant antibiotics over the counter (OTC).
The entire concept and effort of empowerment are rendered null and void if the country’s population is plagued by the recurrence of infectious diseases such as UTI. We must comprehend the holistic health of a female’s mind and body, which differ from that of a male. The fact that both rural and urban women travel like men is frequently overlooked. It is past time to reconsider policies by acknowledging that clean and functional toilets are more important for females than males for anatomical reasons—not only at home but also outside the home.
References:
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3749018/
[2] https://www.semanticscholar.org/paper/A-Study-on-Reoccurrence-of-UTI-in-Indian-Women-Thakur/9fff69afaccbbc040de0d0b8e0cd95ae24f302e1?p2df
[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663160/
[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663160/
[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663160/
[6] https://wcd.nic.in/womendevelopment/national-policy-women-empowerment#:~:text=The%20Constitution%20not%20only%20grants,discrimination%20in%20favour%20of%20women.&text=1.3%20India%20has%20also%20ratified,secure%20equal%20rights%20of%20women.
[7] https://www.downtoearth.org.in/dte-infographics/india_s_health_crisis/index.html#:~:text=This%20is%20in%20contrast%20to,of%20the%20total%20health%20expenditure.&text=Mizoram’s%20per%20capita%20health%20expenditure,GDP%20on%20health%20in%202015.