The Indian non-governmental organisation SPARSH, which has been pushing for a ban on menstrual huts in India, has visited 223 such houses and reports that most of them were in very poor condition – a piece of common village property that no one took responsibility for maintaining.
In a survey among Nepalese students, 28 per cent stated that they are separated from their families during menstruation. The menstrual huts in the countryside in western Nepal are described in detail in feature articles as well as reports from non-governmental organisations and UN bodies. They are often small, lack windows, and can be freezing cold in the winter and too hot in the summer. Most of them lack electricity and other sources of light. In some cases menstruation not only means sleeping separately, but a complete isolation in which no one is allowed to come near the one who is menstruating. The untouchable.
* * *
Sinu Joseph has synchronised her menstrual cycle with the moon so that her period and the full moon coincide. It makes her feel better, she explains when we meet at the conference about menstruation and human rights in Boston in June 2015. She has worked with menstrual education for many years and become the most famous figure in the ‘menstruation field’ in India. She sees herself as an inconvenient truth-teller.
Earlier during the day, she has lectured about menstrual taboos and strongly questioned black-and-white condemnations of rules regarding menstruation, such as menstrual huts. For some women in India, it is a longed-for relief to get away from the duties in the home for a week, she argues. Is anyone asking them, the women in the villages, what they want?
‘Just like with the temple ban, the intention wasn’t to oppress women. The temples are energy centres that can disturb the cleansing process that menstruation is. It’s a misconception that the bans would be about impurity and pollution.’
She holds my gaze. Waiting for my reaction.
Among the researchers, activists, and non-governmental organisations in Boston, she is met with both criticism and cheers. The former because she romanticises menstrual rules and ignores contexts of inequality as well as the actual consequences of, for example, isolation during menstruation. The latter because she demands more knowledge about traditions and questions one-track conclusions.
‘The problem is a lack of understanding and respect for other people’s choices,’ she says.
Sinu Joseph shines the light on routine condemnations.
Menstrual rules are a widespread phenomenon with a long history, marked by various ideas about gender, body, blood, and sexuality. The need for control has grown from the view of menstruation as a force, as a threat against and antithesis to a male norm. In practice, the rules – regardless of origin and intention – become oppressive limitations for many menstruators. In some cases, they violate human rights.
The menstrual hut practice has even turned out to be fatal. There are multiple testimonies about people who have died from snakebites after being forced to sleep outside when there was not enough space in the menstrual hut. Women have suffocated in menstrual huts in the countryside in Nepal. Many have been subjected to sexual abuse when they have slept alone in menstrual huts.
Both the Supreme Court of Nepal and the National Human Rights Commission of India have determined that the isolation is too harmful to be allowed. According to the Human Rights Commission, women are subjected to grave human rights violations relating to, for example, security and dignity.
Norms about the invisibility of menstrual protection lead menstruators to store and dry it in moist and dirty spaces, which increases the risk of infection. It is also difficult to keep it sufficiently clean when the washing has to happen in secret. As a consequence of the secrecy, it can be difficult to get money for menstrual products when men are often responsible for the household funds. And what happens with the person who is not allowed to wash for periods that can last up to a week? Whilst the smell of dried blood amplifies the shame.
Aside from the practical consequences, several of the rules serve structurally as a reinforcement of the prevailing ideology of shame. The silence. The hidden menstrual protection. Bans on sex and religious activities become signs of the impurity of menstruation. Separate sleeping places and meals as well as untouchability stigmatise and set the one who menstruates apart from the norm. Celebrations of menstruation – which have the potential to break the silence and the spiral of shame – risk becoming painful for the young menstruators instead.
Under the regime of silence, it is also difficult to call attention to issues that prevent the one who menstruates from accessing education and work, as well as to increase knowledge within healthcare, and to argue for investments in research. The weight of secrecy becomes a curse.
The limiting potential of the menstrual rules cannot be ignored. As long as the pressing lack of equal distribution of power persists in the world, the question of a free choice about whether to follow menstrual rules is often an illusion. When Kushala stayed home from the temple trip, it was not a choice but a restriction of her ability to move freely and participate in society on equal terms with those who do not bleed.
5
A PAINFUL SILENCE
When Nabirye closes the door, the room becomes pitch-dark. She lights a candle and I think she is smiling. The bed, which she shares with her six daughters, takes up almost all the space in the room they live in. The son usually sleeps on the little floor space that remains. That is also where she washes the pieces of cloth that serve as menstrual protection.
‘I have hooks on the wall so I can hang them up to dry.’
She points, but it is too dark to see anything.
‘God created menstruation. It’s a way of getting rid of dirt, otherwise we would get sick,’ Nabirye says.
It smells of smoke and garbage in Kisenyi, a slum in Uganda’s capital Kampala. Young men and boys stand swaying outside shops and bars, high on drugs. Most of the people who live here are poor, with a daily income of roughly 1–2 US dollars. But there are also wealthier residents. Nabirye does not belong to that group. She takes the temporary jobs she can get to collect money for food and rent, washing the dishes and doing laundry for others. The rent for the room – a few square metres without water or electricity – is approximately 20 US dollars per month. Not too far away, there are sporadically emptied latrines behind doors without locks.
Nabirye gets water from a tap in the area for 0.1–0.2 cents per litre. She washes their clothes in a small tub, sometimes with soap. In order to serve as drinking water, it has to be boiled first. Cholera and other diarrhoeal diseases that spread through water are common here in Kisenyi – as are malaria and HIV.
‘My husband had HIV, and when he died his family threw me and the children out. They took everything we had,’ Nabirye says.
That was when she came to Kisenyi, after first moving to the capital from the countryside in eastern Uganda. She is 41 years old and one of the 1.6 million people in Uganda who live with HIV. A few months after our meeting, Nabirye is hospitalised as a consequence of irregular medication. Access to antiretroviral drugs covers far from everyone in Uganda. Even though they are free on paper, many are forced to pay corrupt managers to get the medication.
* * *
Poverty and disease go hand in hand. If you are poor, the risk that you will fall sick increases; and if you are sick, you risk becoming even poorer. And even sicker. In low-income countries like Uganda, the pressure on the healthcare sector is often extreme, whilst a relatively small proportion of the national budget ends up there. Far smaller than in a richer country like Sweden.
At an individual level, access to care is often determined by your financial means. And therefore also by your gender. When doctor’s appointments, medication, and transport to clinics have to be paid for, it is most difficult for women. They have a lower income and fewer opportunities to travel – even shorter distances. At the same time, they have a special need for care because of their uteruses. More than 300,000 women all over the world die e
very year during pregnancy or birth; 99 per cent of them live in low-income countries. Reproductive (ill) health is a world disaster.
Menstruation also falls under reproductive health, but ends up far down the list of priorities. Because who dies from menstruation? A normal biological function is hardly a threat to one’s health. Or is it?
There are reasons to rethink that attitude. Menstruation is not a disease; rather, it is a sign of good health. But from the bloody pieces of cloth that Nabirye washes and dries in her home runs a trail to various genitourinary infections, a trail that leads on to infertility and miscarriage, in the worst cases to HIV and cancer. A trail that ends here: Menstruation is about the right to health. It can also be about the right to life.
* * *
Cervical cancer is the second most common form of cancer among women in the world. It is difficult to detect. The symptoms come late. Therefore, it is also one of the deadliest forms of cancer in poorer countries, where the kinds of screenings that are offered in, for example, Swedish healthcare are rare. According to the World Health Organization, 90 per cent of all deaths caused by cervical cancer in the world happen in low- and middle-income countries.
A quarter of those who die of cervical cancer live in India. The proportion afflicted is far above the international average. Indian researchers have long hunted for explanations; doctors have sought more preventive measures. So many should not have to get sick and die.
As menstruation became an issue for discussion outside of the private sphere, Indian experts began to look for connections. Could the many cases of cervical cancer in some way be related to the fact that close to 80 per cent of India’s approximately 350 million menstruators reuse cloth as menstrual protection? Cloth that has to be washed during brief moments of solitude and that never dries completely in dark corners. Cloth that is all too often washed in dirty water without soap. Could menstrual hygiene be a question of life and death?
In Uganda, Tanzania, Bangladesh, India, Gambia, Zambia, Kenya, and many other countries, reused pieces of cloth are a common type of menstrual protection, in many cases the most common. That on its own is not a health hazard. There is nothing to indicate that it would be more problematic from a health perspective than to use disposable pads, tampons, or menstrual cups. What matters is how the cloth is handled: washed, dried, and stored.
Fourteen-year-old Saudah in Kampala scrubs her pieces of cloth during the lunch break. Sometimes there is soap at home, or she might be able to borrow from a neighbour, but the supply is irregular. Neither she nor the girls at the other schools in Uganda would even think to dry their menstrual protection anywhere other than indoors. Barbra Chandiru and Catherine Nakabugo at Mackay Memorial College smile indulgently when I ask whether they can hang their menstrual protection up to dry on the clotheslines. To hide it is a rule, a necessity that cannot be compromised – regardless of possible health hazards. Both in Uganda and Kenya, women explain that they would never keep menstrual protection where others could see it. Especially men or children.
Students who participate in a study from Malawi dry their menstrual protection under their mattresses. It is a solution they share with many others. Under beds and mattresses there is a small, protected nook, perhaps the only one in overcrowded families. In Bangladesh, pieces of cloth are wedged into spaces below the roof – with a risk that they might be mouldy when taken back out, explains a woman interviewed by the UN children’s fund UNICEF.
The lack of private spaces and fear of being interrupted force menstruators to wash far too quickly. Soap is a luxury, used by fewer than a third of those who participated in a survey carried out by the organisation WaterAid in Bangladesh. When there is no water, unwashed cloth, hardened by dried blood, is reused.
Over and over again, it is repeated by those who work with menstruation and hygiene. Menstrual cloth must be washed with soap and water. It must be dried in the sun. Sunlight sterilises, even more effectively in tropical countries where the ultraviolet rays and heat kill bacteria. Menstrual protection floating in the wind, drying under the heat of the sun, may be a beautiful image. But it is not grounded in reality. The exhortations are therefore often followed by tips about covering menstrual protection with sheer pieces of clothing, in consideration of the demand for secrecy.
Even though the menstrual flow is sparing when measured in centilitres, it colours the water entirely red. The first and second time around. I empty the sink and turn the tap on again, rubbing with soap that still leaves a faintly discoloured cloth pad. Blood is persistent. In a more washed-out form it turns brownish.
Dirty and moist menstrual protection is a breeding ground for bacteria. And not everyone has access to fabric. The small percentage that is found under the headline ‘other’ in many surveys use what they can find: newspaper, mattress stuffing, leaves, grass, or dried cow dung. The menses must be managed, whatever the cost.
And the price for keeping the blood in check? It itches, stings, and burns. Many menstruators speak of rashes, skin irritations reaching down their thighs. Some speak of parasites. They have discharges that smell bad – yet another source of shame.
* * *
When symptoms reach the healthcare system, they are often diagnosed as urinary tract infection or what is called bacterial vaginosis. Both are conditions that researchers have connected with inadequate menstrual hygiene management. One such study, from the state Odisha in eastern India, attracted much attention. It shows that the risk of infection increases among those who reuse cloth as menstrual protection, but also for those who have far to go to the nearest toilet, and those who lack private spaces to change and wash their menstrual protection.
Urinary tract infections and bacterial vaginosis are frequent among the women of the world. They can be painful, but are rarely immediately dangerous. Not until they are combined with inaccessible healthcare and with particles of a different calibre entirely – like HIV or papillomavirus.
Bacterial vaginosis is a change in the bacterial flora of the vagina. The benign bacteria decrease and harmful kinds increase, with a foul-smelling discharge as the main symptom. In some cases, it can become necessary to treat with antibiotics. The apparently rather innocent bacterial imbalance has been shown to increase the risk of infertility, miscarriage, and premature birth.
There is also a link to HIV. Precisely how has not yet been fully mapped, but bacterial vaginosis seems to pave the way for the virus and facilitate its spread. In a study from 2012, researchers at the University of California write that bacterial vaginosis may be responsible for ‘a substantial proportion of new HIV-1 infections in Africa’. But in order to potentially write the reservation off, more and ever more research is needed.
This is also where Indian researchers pick up the trail that leads on to cervical cancer. Bacterial vaginosis shows up among those affected by preliminary stages of cervical cancer, what is called cell changes. It is in this way connected with papillomaviruses that cause the majority of all cervical cancer. Does bacterial vaginosis pave the way for cancer too? Does it affect resilience? There are indications that this could be the case.
Urinary tract infections are caused by bacteria and can lead to pain and difficulties urinating, among other things. Like bacterial vaginosis, the infection in itself is not dangerous, provided that it is treated with antibiotics if necessary. It is mainly when urinary tract infections are aggravated, left untreated for a longer period of time, that they can cause problems. In the worst cases, bacteria travel upward and develop into an inflammation of the kidneys. The bacteria can then reach the bloodstream and cause blood poisoning, which is a life-threatening condition.
This trail is not entirely clear; it is followed by question marks and uncertainty. If there is anything that all researchers maintain, it is the acute need for more knowledge. Belen Torondel, one of the researchers behind the study in Indian Odisha, writes in an email: ‘It is very important to continue studying which factors related to menstrual hygiene management are
associated with infections to be able to provide good recommendations. This is an area that has been neglected for so long.’
The fact that it is a low-priority and underexplored area has several explanations. It is likely that the combination of woman, sex, and poverty is critical – as a result of gender-discriminatory practices, moralistic notions, and economic interests.
Yet the trail is there. From the dirty laundry water, the lack of soap, and the hidden menstrual protection to physical ill health. Genitourinary infections form a large category, which also includes fungi and various sexually transmitted diseases. Together, they pose a huge health problem that grows and worsens with poverty. For many, feeling pain, itching, and being ashamed of smelling is a part of everyday life. All this is really enough, notwithstanding more serious medical consequences. But the silence puts a lid on uteruses, ovaries, and vaginas.
* * *
Menstrual protection and health hazards are not just a question of significance in low-income countries, nor solely for the one who reuses fabric as menstrual protection. Bacteria can also grow in disposable products like pads and tampons, mainly if they are changed too infrequently. Since the 1970s, it is for example known that tampons left in place for too long – in rare cases – may cause the potentially deadly condition Toxic Shock Syndrome (TSS).
In the US, the harmful potential of menstrual protection has long been an issue for feminist activists who demand more information about what the products contain, something which manufacturers are under no obligation to declare, neither in the US nor in Sweden. A variety of plastics, chlorine bleaching, and cotton grown with strong pesticides raise concerns. Since 1997, the American Democratic Congresswoman Carolyn Maloney has tried to pass a law with stricter requirements of transparency and lobbied for more research into health risks – so far without success, which she has attributed to the fact that it is difficult to arouse interest in women’s health and that ‘the safety of tampons is not something that is on the minds of many members of Congress’.
It's Only Blood_Shattering the Taboo of Menstruation Page 7
