Why Toilets Matter

In August of last year, a Bollywood movie called Toilet: Ek Prem Katha, which translates to Toilet: A Love Story, debuted about a woman in India who left her marriage because her husband wouldn’t build a toilet in their house.

It sounds farfetched, at least here in the United States, but it’s actually based on a true story. And it highlights a very real, very serious issue in much of the developing world: Many people defecate, by choice or necessity, out in the open. In India alone, it is estimated that 70 percent of households don’t have working toilets.

Where does this leave schools?

As Anjali Adukia, Ed.M.’03, Ed.M.’12, Ed.D.’14, learned when she started doing research for her dissertation on this topic, the answer was pretty grim: not in a good place.

Even as recently as two years ago, nearly 40 percent of the 1.5 milion schools in India lacked a bathroom; the percentage was even higher when looking at usable bathrooms specifically for girls. Adukia, who has worked in India and whose parents grew up there, learned that not having a bathroom was not only inconvenient, but highly detrimental for students and teachers, especially girls and women. Urinary tract infections and kidney problems from holding it in. Anxiety over being seen going outside. Fear of being taunted or raped. Missed school days. Dropping out.

It was these consequences that led her to devote much of her time while a student at the Ed School to looking further into what impact access to sanitation facilities, such as toilets, have on education and learning — research she has continued as an assistant professor at the University of Chicago.

“Sanitation matters,” she says. “Sanitation is an understated, underappreciated issue.”

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Adukia first became aware of toilets — or the lack of them in India — before she began studying at Harvard, when she spent a little more than a year living in Ahmedabad, in western India, about 300 miles from Mumbai, her parents’ hometown. While working there with two ngos, Manav Sadhna and Safi Vidyalaya, she often visited the nearby Gandhi Ashram, where she learned that Indian leader Mahatma Gandhi cared deeply about sanitation and believed that it had the power to transform a nation, not only in terms of hygiene, but also self-respect. “Sanitation,” he once said, “is more important than political independence.”

A couple of years later, while a student at the Ed School, Adukia went back to India and the issue of sanitation came up again.

“Between my first and second years, I was working in India on a microfinance project,” she says. “I was visiting homes and schools, trying to understand decision-making. I eventually started asking girls where they went to the restroom when they were in school. In one case, they pointed to school grounds or behind signs, and that’s when the story came out: A girl they knew got assaulted by some boys when she went to urinate behind some bushes and the girl’s parents took her out of school.”

The girls she talked to were really enthusiastic about learning but worried that the fate of their friend could easily become their fate. To prevent this, they confessed to Adukia that they wouldn’t drink or eat anything all day. They sometimes felt dizzy. They often were unable to concentrate. But for these girls, this was better than relieving themselves outside during the school day, in the open, where they felt self-conscious and they worried that boys and men would watch them or, worse, hurt them. They worried they’d also have to leave school. Curious, Adukia started looking into the existing research on dropping out and possible connections to not having a bathroom. In 2000, as she writes in a recent paper, Sanitation and Education, “India was home to almost 20 percent of the out-of-school children in the world, with approximately 20 million children not enrolled in school.” Girls accounted for about 59 percent, with the percentage going up as they got older. According to The Guardian, girls in India make up two-thirds of illiterate 15- to 24-year-olds.

What Adukia found doing her research included some of what she expected: Both boys and girls sometimes dropped out of school to get married or work. For girls, there was also the added issue of their monthly periods.

“Some research on the high level of dropout rates for girls tends to focus on menstruation,” Adukia says. Cultural beliefs in the country sometimes label menstruating girls and women as impure and dirty. She learned that, as a result, girls often stay home from school when they have their periods, especially if they attend a school that doesn’t have a restroom devoted for girls’ usage only, or even any restroom at all. If they miss too many days, they may eventually drop out.

But Adukia knew that the reasons mentioned in the research for dropping out — marriage, work, and menstruation — didn’t fully tell the story. These reasons didn’t explain the everyday effect of not having a bathroom at school — the reasons she was hearing in her conversations with girls in India.

“This overly narrow focus on those few days of a girl’s period,” for example, “overshadows larger issues like privacy and safety that girls face every day in not having secure bathrooms at school,” she says. (When she spoke with boys about dropping out, they mentioned work or obligations at home, never privacy and the lack of a bathroom, except in veiled ways about a male “cousin” or “friend.”)

Boys may not have been sharing their concerns, but many families were: They were so concerned about the lack of bathrooms that some stopped sending their daughters to school, especially once they became preteens.

“I realized they deeply cared about their children, so much that they didn’t send daughters because they cared about their safety and their honor,” Adukia says.

According to unicef, 50 percent of rape cases in India occur when women go to relieve themselves in the open. In 2014, in a case that received wide media attention, two teenage girls were raped, brutally attacked, and found hanging from a tree after going outside because they had no indoor toilet at home. Adukia knew she needed to take the research further.

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Luckily for her, the Indian government was a lso starting to understand the link between bathrooms and education. In 1999, the government began a push to end open defecation in the country as a way to improve security for girls and reduce disease for everyone, but especially children. According to UNICEF, almost 1 in 10 children in India under age 5 dies every year from diarrhea, which is linked to poor water, hygiene, and sanitation. About 40 percent of the country’s children are stunted — chronically malnourished — a condition which is also linked to open defecation.

One way to combat this, the government hoped, was to build more bathrooms in more schools. At the time, anywhere from 450,000 to 500,000 schools in India didn’t have latrines.

“This is across the board,” Adukia says. “Private schools in villages don’t necessarily have restrooms, either.”

Called the School Sanitation and Hygiene and Education (SSHE) program, the government collaborated with UNICEF, which launched similar initiatives in six other countries. Construction of bathrooms began in 2001 and increased sevenfold in 2003. Most schools received simple pit latrines, which did not require piped water. Some were unisex, some for girls only, and others built separate facilities for both boys and girls. The program was run by the Ministry of Drinking Water and Sanitation, not the education ministry, which Adukia says was actually an initial positive for schools.

“There was no financial trade-off for schools,” she says. “They didn’t have to choose: either a bathroom or chalkboards. This was a sanitation initiative.” Between 2001–2006, 230,000 bathrooms were added to schools that previously had none.

This program was just what Adukia needed. Using data from 140,000 schools spread throughout 269 low- and middle-income districts, plus a smaller sample provided by an NGO, Adukia compared schools that had received a latrine through the government sshe program with schools that didn’t, then looked more deeply at what type of latrine was added (unisex or gender specific) and the age of the students using them.

She was trying to figure out if having access to something as simple as a safe bathroom during school hours really would make a difference in getting more kids, especially girls, to attend and then stay in school, and if the type of bathroom mattered. While the education world debated and strategized about ways to improve outcomes for students around the world, Adukia suspected the answer to her question was yes.

“Let’s talk about Maslow’s hierarchy of needs,” she says. “If you don’t have your fundamental needs fulfilled — needs such as safety and hunger — then it’s much harder to focus on higher-order concerns or issues and other interventions may not be as effective as they could have been otherwise.”

Still, when she first mentioned her bathroom research idea to other academics, she was met with raised eyebrows.

“The NGO world was like, of course toilets matter, but in the academic world, they were skeptical that toilets mattered because what is a toilet?” she says. “To some it’s just another widget. The key is to think about what a sanitation facility could provide: health and privacy, and potentially safety.”

Academics weren’t the only skeptics, though. When she first talked with headmasters and other school leaders in India about this link between bathrooms and learning and staying in school, they too wondered why she cared so much.

“‘Kids are on regimented schedules,’” they would say to her, as she explained during an interview with the Chicago-based Radio Harris. “‘They either go before they come to school or after they get home, and if they really need to go during the day, they just go out into the beautiful open like we’ve been doing for centuries. There’s nothing wrong with that.’ There was this idea that it was better to go out in the open. It’s clean. It’s nature.”

It’s a belief that is common in the country, especially in rural areas. According to the World Health Organization, India accounts for 59 percent of the 1.1 billion people in the world who practice open defecation. Many resist the idea of indoor sanitation. Going outside is the way it’s always been done, some argue. Having a toilet under the same roof as the kitchen is impure. There are also practical reasons: It costs too much. There is no one to build them. There is no one to keep them clean.

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What Adukia found after analyzing her data (which took a year to get and involved a funny interaction with a monkey) was promising. Generally, adding latrines increased total student enrollment in primary schools by 12.1 percent and in middle school by 7.9 percent. And girls benefited more than boys: The new bathrooms increased enrollment for girls in primary schools by 11.1 percent, compared to 9.7 percent for boys, and in the upper grades by 7.1 percent, compared to 4.7 percent for boys.

She also found that the type of bathroom mattered. From the sample she studied, she found that “among the middle schools that built a latrine, 38 percent built unisex latrines, and 50 percent built separate sex-specific latrines. Among the primary schools that built a latrine, 48 percent built unisex latrines, and 46 percent built separate sex-specific latrines.” Bigger gains were made for both girls and boys (although more for girls) when latrines were same-sex only.

Adding latrines also decreased dropout rates, reducing the fraction of students who dropped out by 5.3 percentage points in the middle schools and by 12.2 percentage points in primary schools.

“Why would a latrine matter? It could be that kids are able to better concentrate, it could be that kids are healthier,” she says. “For younger children, you see substantial impact regardless of whether a private or a shared sanitation facility is built. This suggests that their decisions are driven by increases in health and the healthiness of the environment. However, pubescent-aged girls seem to mostly only respond if there is a separate restroom designated for girls, which suggests that privacy and safety concerns are central to their decisions. Regardless, you’re getting more kids staying in school.” And staying in school has important implications beyond just learning or increased earning potential. “By staying in school another year, you’re delaying marriage by a year, delaying potential childbearing for another year. Studies also show that an additional year of schooling can help increase life expectancy, decrease the mortality of the next generation (child mortality), and reduce inequality generally.”

There are also benefits for teachers when a school has a bathroom, especially for female teachers who work in a male-dominated profession. “For every woman in the teaching profession in India, there are two men,” Adukia says.

“If you imagine that privacy begins to matter when puberty hits, well, it doesn’t end when puberty ends,” she says. “It matters for adult women, too. If you’re a female teacher and a school doesn’t have sanitation facilities, you may be less inclined to work there or show up for work every day. Female teachers do care about this.” She says that up to 25 percent of teachers don’t show up daily in India.

When she asked female teachers why bathrooms matter, they spoke about wanting privacy. “They did not generally speak of potential physical harm from the students, though there were concerns about physical harm from men in the village. Some teachers at a high school did talk about safety concerns, but this was possibly because the students were older.” Regardless, “teachers would want to relieve themselves, and in the absence of a private restroom, they would put themselves at risk of exposing themselves to their students. Privacy matters for adults too.”

It certainly affected where female teachers chose to work. Although she doesn’t have data on attendance, she found that the number of female teacher increased at schools that constructed latrines. Adding a bathroom increased the percent of female teachers by 1.8 percent overall and 4.4 percent when a school added a restroom specifically designed for female students and staff.

Anecdotally, she says having more female teachers can also increase the number of girls who attend or stay in school. These girls see them as role models or may just feel safer in their company. She writes in Sanitation and Education, “Some parents in conservative communities do not allow their daughters to be taught by a male teacher, due to safety concerns. Some girls also fear sexual harassment by male teachers and feel safer with female teachers.”

And all students benefit from having a teacher who is present regularly.

“Many of these schools have only one teacher,” Adukia says, “so if a teacher is absent, the school is effectively closed, thus removing access to education for those students on that day.”

Although much of her work focuses on the attendance of girls, Adukia is quick to point out that bathrooms matter for boys, too, even if they don’t say it matters. In the child psychology literature, she says, boys, especially young boys, are most often the silent victims of bullying. During field interviews with boys, when they talked about a sensitive issue like bathrooms, the boys would immediately switch to talking about “a friend” or “a cousin.”

“There was a stigma for boys, especially when they reached puberty, to talk about their desire for more privacy or security,” she says. Even though they used stories about friends and cousins, she knew that having access to bathrooms mattered. “This action benefits both girls and boys. There are multiple stakeholders in every issue. We want everyone to improve.”

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Of course, since the government started building bathrooms at schools, there have been setbacks. Even when a toilet was added, in some schools it hasn’t helped students. Sometimes they are locked and used only by teaching staff. They are used as storage rooms or cow sheds. Other times, despite urgings from the government or Bollywood movies, cultural norms are so pervasive that students just don’t think to use them. Too often, bathrooms are shut down because they aren’t cleaned regularly.

“A big issue is that sshe funded construction but did not provide for maintenance,” Adukia says. This is also the case for another recent government campaign called Swachh Bharat: Swachh Vidyalaya, or Clean India: Clean Schools. “UNICEF’s recommendation was that the students should be in charge of cleaning the restrooms. Anecdotally, this led to many unintended consequences such as it being used as a punishment, or only the lower-caste students or female students were asked to clean them. Sometimes teachers had to add the responsibility to their already full plates, and then they would not get cleaned.”

Still, the issue is staying on the radar and gained steam a few years ago when Prime Minister Narendra Modi was running for office and spoke publicly about public defecation, calling for every school to have a separate bathroom for boys and girls.

“‘Toilets before temples’ was part of Prime Minister Modi’s campaign slogan,” Adukia says. As he said during a campaign stop, “Villages have hundreds of thousands of temples but no washrooms. That is bad.”

In 2014, after he was elected, during a speech at an Independence Day celebration, Modi specifically appealed to what girls and women face. “We are in the 21st century, and yet there is still no dignity for women as they have to go out in the open to defecate and they have to wait for darkness to fall. Can you imagine the number of problems they have to face because of this?” Adukia says Modi’s attention to the issue has been powerful.

“It was extremely meaningful to have a prominent public figure use the spotlight for such a real and not glamorous issue,” she says. “People are now much more aware. You see corporations shift their funding priorities, ngos start to focus more on the issue, more policy coherence across education and sanitation sectors. It’s definitely shifted the previously prevailing paradigms. However, more needs to be done in terms of sustainable mechanisms and funding for maintenance in addition to ensuring that these restrooms get used.”

Another campaign, called No Toilet, No Bride, went directly to the people. With billboards and radio jingles, the campaign popularized the saying, “No loo? No I do.” One soap opera even wove the message into a story plot: future brides don’t marry into a house without a toilet.

According to a 2017 Journal of Development Economics study, efforts like these may be working. Since the No Toilet, No Bride campaign started, for example, private bathrooms in the northern state Haryana increased by 21 percent in households “with boys active on the marriage market.”

As one young man, Harpal Sirshwa, told The Washington Post at the time, “I will have to work hard to afford a toilet. We won’t get any bride if we don’t have one now,” he said. “I won’t be offended when the woman I like asks for a toilet.”Adukia is also feeling confident that her findings about kids enrolling and staying in school will hold up over time. As she points out, this wasn’t just a study of a handful of families — this was 140,000 schools in 269 geographically diverse areas, with different cultural norms.

Since becoming an assistant professor at the University of Chicago, Adukia continues to make sure her findings aren’t relegated to academic journals and conferences. She started working with UNICEF to further disseminate what she’s found and to expand the research. She has presented her findings to international groups like the World Bank and to local ngos interested in improving conditions for children, especially the most disenfranchised.

Looking ahead, Adukia says that no matter where her new work takes her or how big the next dataset gets, she is always cognizant that she is working with real people who are living their lives. “It’s always important to remember that ‘human subjects’ are humans first and foremost,” she says. “It can be easy for researchers to get caught up in their research questions or agenda. No matter the kind of question one is asking — and if you’re taking up someone’s valuable time for your research, you want to make sure that what you’re asking about is important — you must always respect the individual.”

Adukia photo: Paul Elledge

Other photos: Getty Images

Watch a video about Adukia defending her dissertation from that funny monkey.