In this community, having your period lowers your status to that of a dog.

For Radha, dinner is served at 7. She crouches down behind a shed, a good distance from her house, then waits. She knows what the menu will be: boiled rice, the same as yesterday and the day before. She knows that it will be her little sister who will serve it, throwing the rice onto her plate from a height, the way you would feed a dog.

In Jamu, Radha’s village in western Nepal, her status is lower than a dog’s, because she is menstruating. She is only 16, yet, for the length of her period, Radha can’t enter her house or eat anything but boiled rice. She can’t touch other women – not even her grandmother or sister – because her touch will pollute them.

If she touches a man or a boy, he will start shivering and sicken. If she eats butter or buffalo milk, the buffalo will sicken too and stop milking. If she enters a temple or worships at all, her gods will be furious and take their revenge, by sending snakes or some other calamity.

Here, menstruation is dirty, and a menstruating girl is a powerful, polluting thing. A thing to be feared and shunned.

After dinner, Radha prepares for bed. Darkness falls fast in Jamu and without mains electricity, the villagers follow old rhythms and sleep with the dark. Radha’s parents are both migrant workers in India, so she lives with her grandmother. Their house has a solar-powered light, as does the one opposite, where I’m staying with my travelling companions: the Communications and Gender Officer for WaterAid Nepal and our photographer.

The light is no use to Radha this week because her bed is elsewhere. She leads me over the thoroughfare of pebbles and rocks that passes for a road, suitable only for motorcycles and walkers. Cars and buses must stop at the river, a four-hour walk away. We walk up a steep hill, through long snake grass, to a small lean-to structure. It looks like an animal shed, but is smaller and meaner. This is the shed where the village’s menstruating women and girls sleep.

In the winter, Radha sleeps on the tiny enclosed ground floor, no bigger than a crawl space. The summer accommodation is an earthen floor on a platform above, four-foot square. Except for a grass roof, it is open to the elements.

There is not space even for one person to lie down, but tonight there will be three. Radha’s relative Jamuna is also menstruating, and she’ll be sleeping here along with her one-year-old son. Still, Radha appreciates the company, as another woman is some protection against drunken men who conveniently forget about untouchability when it comes to rape. Although the stigma keeps women silent, rapes of women sleeping in these sheds are common enough to appear as occasional items in newspapers in faraway Kathmandu, and common enough for women to look down when they are mentioned. Also common are snake attacks. (I saw three snakes there in three days.)

Sometimes there are four or five women in the shed, an unthinkable number. If the shed is that full, then girls and women must find other options. Up the field, I watch with disbelief as a 14-year-old girl shows me her sleeping arrangements for the night: the bare earth outside her family’s house, with only a mosquito net for protection. It’s only the third time she has had her period and already she is resigned. What can she do?

In the local dialect, Radha, her relative and the 14-year-old girl are ‘chhau’ (sometimes ‘chau’). Originally meaning ‘menstruation’ in the Rawte dialect of Achham, it has come to mean ‘untouchable menstruating woman’. The system of keeping girls and women apart is known as ‘chhaupadi’ (‘padi’ means ‘woman’).

Menstrual taboos and restrictions are still practised in dozens of countries across Asia and Africa. In neighbouring India, I met girls who told me that their nail polish went rotten if they applied it during their period, and that they were forbidden from touching pickles. But chhaupadi is one of the most severe and damaging examples. In 2005, Nepal’s Supreme Court declared it illegal. Three years later, the Ministry of Women, Children and Social Welfare issued guidelines meant to eradicate the practice.

But western Nepal is remote both geographically and legislatively, and enforcement is rare. A 2010 survey in the mid- and far-western regions found that 19 per cent of women were forced to live in chhaupadi sheds, but this figure rose to 52 per cent in the mid-western mountain areas and 50 per cent in the far-western hills.

We are in the mid-west, but not in mountain country where the practice is more endemic, so I wasn’t sure of finding chhaupadi sheds. The first village we encounter is Narci, an hour’s walk after the road runs out.

There is a chhaupadi shed outside every house. Some contain possessions: a comb stuck in the thatch or a bottle of red nail polish. Some have schoolbooks.

In Narci, a group of women gather to talk, sitting at a safe distance on the steps outside a house, as one, Nandakala, is menstruating and she doesn’t dare come closer. Her chhaupadi shed is nearby. She says, along with all the other women, that chhaupadi is necessary. If menstruating women don’t observe the taboos, bad things happen. A buffalo could climb a tree. Men would start trembling and fall ill. Snakes will be brought by the sin. A woman holding a small scythe gets animated at this: “Yes, it’s true. A big snake came into my house.”

In this group setting, none of them protest. They accept their situation, even the lack of sanitary pads. “We don’t even wear underwear. What do you expect? We are jungle people.” Instead, they let the blood flow, or make a sort of loincloth from old saris that they tie between their legs. As for washing and drying the cloths, that must be done in secret, if at all. It is discreet, but also dangerous: unless menstrual cloths are properly washed and dried in sunlight, they can be a health hazard.

The women shrug. It is our tradition, they say. It’s what our parents and grandparents did, so it’s what we do. But away from the group, as she has her picture taken in her miserable chhaupadi shed, Nandakala is more frank. “Of course I hate it,” she tells the photographer. In the winter it’s cold. In the summer it’s hot. The restrictions are stifling and unfair. “Why should the gods punish us? Why should women be punished? But what the hell can we do?”

On the four-hour road trip from Nepalgunj, the location of the nearest airport, we encountered signs in Nepali, declaring villages to be ODF (open-defecation-free), meaning that they now have adequate toilets. But many do not: 15 million people in Nepal – about half the population – have no toilet. Just under 8,000 Nepali children still die every year from water- and sanitation-related diseases (most from diarrhoea), according to WaterAid. Those deaths are usually caused by faecal particles getting into food or water, and would be easily prevented by decent sanitation, clean water and hygiene.

On paper, Nepal’s commitments to sanitation are impressive: the government plans to ensure 53 per cent sanitation coverage nationwide by 2015, rising from 43 per cent in 2009. But its efforts to reduce menstrual taboos and chhaupadi are less admirable. Despite the Supreme Court’s judgement, menstrual taboos are so far from being eradicated in Nepal that they have their own national holiday.

In early September in Nepal, Hindus – who make up 81 per cent of the country’s 30.5 million people – celebrate Rishi Panchami, a festival that commemorates a woman who was reborn as a prostitute because she didn’t follow menstrual restrictions. It is a women’s holiday, and so Nepal’s government gives all women a day off from work. This is not to recognise the work done by women but to give them the time to perform rituals that will atone for any sins they may have committed while menstruating in the previous year. (Girls who have not begun menstruating and women who have ceased to menstruate are exempt.)

At 3am, we find thousands of women queuing up at the Pashupatinath temple, Kathmandu’s grandest, ready to atone. They are not ignorant about the nature of the rituals, as I crassly expected them to be, nor is this something done by rote. “We may have touched a man by mistake,” they say, queuing so tightly that the line looks like a mile-long embrace.

“We have to do this because our ancestors did.” Even the female police officers standing nearby see nothing wrong with it. “I can’t do the rituals this year because I’m on duty,” says one, holding a cup of warm tea in the cold morning darkness, “so next year I’ll do double.”

She is serious, and so are the five women we find at a river’s edge nearby, ritually washing themselves 365 times. Dressed in red petticoats, a sacred thread around their waists, they spend hours performing the ritual washing of their private parts, belly button, elbows, armpits, heart and head, while men on the far river bank suddenly find the need to do an hour’s calisthenics right in front of these near-naked women. The women finally cleanse their hair by smearing it with fresh buffalo dung, before washing it with cow urine and milk. I ask the eldest woman whether she believes she has sinned. “Well if I didn’t, I wouldn’t have done all this, would I?”

Rishi Panchami enrages many educated Nepali women. It’s not so much the superstition but the legitimacy that the government gives it by providing a holiday that declares women to be dirty and polluting. At a menstrual hygiene event put on by WaterAid in Kathmandu, Ashutosh Tiwari, WaterAid’s Country Representative for Nepal, made an explicit but unpopular case. “You might wonder why a water and sanitation NGO is talking about menstrual hygiene. It’s because we are trying to make the important point that for women’s empowerment we should start with something like menstrual hygiene.”

Even so, menstrual hygiene is a hard sell for many sanitation and WASH (water, sanitation and hygiene) NGOs. Privately, female Nepali sanitation activists tell me that their male colleagues see no need to object to chhaupadi or Rishi Panchami because it is tradition. This cultural relativism is both wrong and costly: it’s well established by now that countries with poor sanitation pay for it.

India loses 6.4 per cent of its GDP to health and other costs caused by its lack of sanitation (untimely deaths, productivity lost to ill-health or disease, hospital beds used by patients with sanitation-related diseases). Globally, poor sanitation loses the world $260 billion a year. No economic research on the costs of not having clean water and sanitation has yet been done in Nepal. But in nearby Pakistan, the total economic loss caused by poor sanitation is equivalent to 3.9 per cent of its GDP, and across all low-to-middle-income countries, the average loss is 1.5 per cent.

The specific health impacts of poor menstrual hygiene have been little explored. Anecdotally, the use of unhygienic menstrual protection has been linked to reproductive tract infections such as bacterial vaginosis and vulvovaginal candidiasis, as well as secondary infertility, urinary tract infections and anaemia. Yet a 2013 survey of existing research literature found that evidence to support any link between poor menstrual hygiene and these conditions was “weak and contradictory”. “Raising awareness regarding menstruation and hygienic practices,” the authors wrote in their conclusion, “has remained largely a neglected area in terms of research, despite its increasing popularity amongst public health organisations.” 

There are other costs. A PlanIndia study in 2010 found that 23 per cent of Indian girls dropped out of school permanently when they reached puberty, and that girls missed school for an average five days a month each for the lack of decent sanitation or menstrual products. Their schools had no toilets or had disgusting ones, or there was no privacy. They had struggled for years without toilets, but when they began to menstruate, it got too difficult. It was easier to drop out.

We know already that better-educated girls are less likely to die in childbirth or of HIV/AIDS, are more likely to use contraception, are more likely to know about good child nutrition, and generally have a better chance of a healthy and productive life. As such, any sign that school dropouts are linked to menstrual hygiene should have government officials in education, development, empowerment and health rushing to build safe toilets and talk loudly and frankly about periods – if they weren’t as hampered by taboo as those women in their petticoats performing rituals to right imaginary fault.

On my second day in western Nepal, we walk 90 minutes to Tatopani, a village of 95 households that contains an excellent food shack, the village government offices, and 16-year-old Radha’s school. Along the way, the chhaupadi sheds, initially visible in every yard, become rarer. This is because Tatopani has launched a chhaupadi minimisation programme, and it’s working.

In the village offices, a group of concerned citizens has gathered. Some sit on the village WASH committee. Some are health workers. Two are young men, a rare sight in these villages because nearly all the men have gone to India to work. Green paddy fields, dramatic forests and rushing rivers do not compare to earning a decent wage as a security guard or labourer.

The young men are the most passionate. Their families migrated here from the far-western region of Achham, where chhaupadi is even more rooted. But Achham is also where the first chhaupadi-free villages have emerged, and where a government minister’s wife in 1998 became the first menstruating woman in her district to spend a night in her own house.

In earlier times, the villagers tell me, the menstrual restrictions probably made sense. Women could have a few days’ rest while they were weak from blood loss. The men were around to do the chores and there were family members to do the cooking. Things are different now. The men are gone, the women must still work, and the deprivation and damage done by chhaupadi is greater.

“They have to stay outside but still do all the difficult jobs,” says Kabi Raj Majhi, a young man who is the most vocal of all the villagers and the chair of the committee. When WaterAid’s local NGO partner NEWAH (Nepal Water for Health) arrived in the village to build a water point, they saw an opportunity to change things. “They said women should be allowed to use the main water point even when they were menstruating,” says Kabi. “A traditional healer objected, and they said, fine, use another water point then.” He soon capitulated.

An old man in the corner begins to speak: “Before, they were kept outside for seven days. Now it’s five and I think that’s fine, but it should stay at five.” He knows that chhaupadi is necessary because of what happened during Nepal’s civil war, when 17,000 people died. These western regions were full of Maoist rebels. “When the Maoists were here,” the old man says firmly, “they didn’t observe chhaupadi. They let women in the house. And then the Maoists died in the war.”

The others shout him down, but they are realistic. The problem isn’t men like him, or traditional healers. “We can change them,” says Madan Kumar Majhi, Kabi’s cousin and a member of the chhaupadi minimisation committee. “But it’s the women who are the barrier.” The mothers and mothers-in-law are the worst. A female community health volunteer tells the room how she pretends to be menstruating just so her mother-in-law starts shaking and trembling and pretending to be sickened by chhaupadi. “But when I am actually menstruating, I touch her and nothing happens.” She laughs, but still she has to observe the taboos.

Change comes slowly and it is still limited. “Sometimes,” says Kabi, “we have only got the women to be allowed to sleep inside the compound. We are trying to persuade people to set aside a separate room for chhaupadi. We know it’s not perfect, but we are trying. There’s no electricity in chhaupadis so it’s damaging girls’ education.” Before, it was worse: girls weren’t allowed books because they were considered symbols of the goddess of knowledge.

A short walk away, I sit down with a group of girls at Radha’s school. They have come in specially to talk to me, even though there is a government strike today and school is closed. Nepal’s government is fragile and any political party can call a national strike, which happens frequently. These girls, though, are not fragile. They are feisty and smart.

They say that chhaupadi is embarrassing. “We know that you don’t do it,” says Pabitra, 17. “They don’t do it in developed countries.” But only four out of a dozen have been freed from sleeping outside in chhaupadi sheds. “It makes no sense,” says Anjana, whose mother is a health worker. Her mother came home two years ago and said they weren’t going to do chhaupadi any more. “Women bleed even more during childbirth but they can stay in the home. Goddesses are women, aren’t they? They bleed but they’re allowed to stay in the temple. Why can’t we?”

She knows the answer. “It’s a lack of education. People think that because it’s an old practice, it’s authentic and powerful.” She says they talk about menstruation in their health lessons at school. “The teacher tells us it’s not a good thing.”

It is an irony of chhaupadi that talking about periods is easier in Nepal than in many other countries. Research in Karachi, Pakistan, for example, found that one in two girls aged 14 to 17 knew nothing about menstruation. But these girls in Tatopani knew exactly what to expect when they started their periods, because they had seen their sisters and mothers move out to the shed. So they talk openly – more openly perhaps than the average teenage girl in the UK might – about what they use for sanitary protection. Some use sanitary pads, some are happy with cloths, although they dry them by hiding them under other clothes on washing lines.

When I ask them what they want to do when they leave school, they all say the same thing. Leave this place. Never be a housewife: see how they suffer! They want education and freedom. “I want to be a social worker,” says Anjana. “If I learn, I can teach these people and maybe I can change them.”

On the factory floor

On any given day, 300 million of the two billion women and girls of menstruating age across the world will be bleeding. On any given day, the taboos, restrictions and ignorance about menstruation will be costing millions of dollars, and damaging development, health and wellbeing.

The connection between installing sanitation and income is now well-known: investing a dollar in sanitation can save a country up to $8 in avoided costs. It’s likely one of the best health bargains we know of. But it has taken years for sanitation to be spoken about openly. In 2000, when the Millennium Development Goals – a set of global self-improvement wishes to be achieved by 2015 – were announced, sanitation wasn’t even included, even though diarrhoea was then – and remains – the second biggest killer of children under five. Even after countless battles, sanitation has only become a sub-target of a sub-goal. In the Post-2015 Development Agenda, meant to update the Millennium Development Goals, things had improved. There is now no question of ignoring sanitation, but there is still silence around menstruation.

Even in high-income countries, menstruation is supposed to stay hidden. I grew up in the UK, where sanitary pads and tampons are widely available, as are clean, private toilets in which to change them and bins in which to dispose them. But I have never excreted the blue liquid used to represent blood by anyone advertising sanitary pads, nor have I ever seen a sanitary product that isn’t being advertised for its discretion.

In 2012, I spent three weeks on a travelling sanitation carnival in India, the Great WASH Yatra, where one of the stalls was a Menstrual Hygiene Management Lab. Of the 12,000 women and girls who came to the lab, 71 per cent had had no idea what was happening when they started their periods. Most thought they were injured; some thought they were dying. “In much of the developing world,” writes Dr Catherine Dolan of the University of Oxford’s Said Business School, “menarche [the onset of menstruation] is a fraught process, characterised by uncertainty, fear and distress.” The concealment and silence around menstruation causes damage to women’s health and education, and also to their economic prospects. And it is widespread.

In 2010, a new initiative began in Dhaka, Bangladesh. HERproject (standing for Health Enables Returns) is a programme run by Business for Social Responsibility (BSR), a membership organisation of 250 companies worldwide, including Microsoft, Sony, Pepsi and Coca-Cola. Dhaka was an appropriate place for a business-backed NGO, because many BSR members source products from Bangladesh’s 5,000 garment factories. There are three million Bangladeshis working in the garment industry, and 80 per cent are women.

Although the ethical sweatshop-free movement of the last 20 years has led to big changes in the garment industry, tragedies still happen and, when they do, they are devastating. When the Rana Plaza factory building in Bangladesh collapsed last year, 1,133 people died. Access to factories is difficult for NGOs, who can be regarded with suspicion by factory management. HERproject, though, had the backing of its members, who understood that healthy workers are better workers. “And the need was enormous: most garment workers arrive in the cities with little education,” Nazneen Huq, HERproject Bangladesh’s director, told me. They come aged 16 or younger, but with a certificate from the village leader saying they are 18. They leave their villages too soon to benefit from rural NGO programmes, and there are barely any NGOs working on hygiene or education in urban areas.

With the clout provided by BSR’s members, such as Timberland, H&M and Primark, HERproject Bangladesh, under Huq, gained rare access into the factories, and initiated discussions. The remit was broad: to improve the health of female workers. Workers are educated in nutrition, HIV/AIDS and other sexually transmitted diseases, and hygiene. All of these things are crucial. Female workers in Dhaka’s factories told HERproject facilitators that nutritious food was for rich people. “They thought that lentils or pumpkin were poor people’s food,” says one facilitator who accompanied me on factory visits. “So they didn’t eat it. We had to tell them that poor people’s food and rich people’s food have the same vitamins.”

But Huq also needed to talk periods. She knew from her work in Pakistan that menstrual hygiene among factory workers was poor. Factory managers freely admitted to her that their female workers were not turning up for work for several days every month. When a factory operates on production lines, a missing piece-worker is noticed.

Huq, who has worked with garment factory workers for years, had two simple implements: frankness and economic loss. “They knew that women were going absent, and they knew that it had to do with periods, but they didn’t dare talk about it,” she says. Her tactic was to focus on what they would talk about, which was business. “I would say, ‘If you have 1,000 workers who are women, and each woman is absent one to three days…’ They answered, embarrassed, ‘Yes, yes. If 500 are absent for one day you lose 500 productive days.’ Then they get very shy, but they say, ‘Yes. It makes sense.’”

All these factory managers knew about workplace safety, they just hadn’t thought about health, beyond providing the medical centre required by law. They didn’t appreciate the ways that poor health costs them money. They didn’t know, for example, that 80 per cent of their female workers didn’t use sanitary pads.

One of the first factories that joined HERproject is in Ashuria, a suburb just a few miles from downtown Dhaka, but a three-hour trip in the city’s appalling traffic. It is a good factory, as factories go, and all the workers are wearing homemade masks, sometimes made from material covered in cartoons that will become children’s leggings or pyjamas. It is properly ventilated, and there are decent toilets. Downstairs, there is a crèche.

Sarita*, a 25-year-old worker, comes away from her post on the finishing section to talk. The HERproject model works by educating peer educators, who are then responsible for disseminating information to 20 other female workers.

Sarita came to Dhaka four years ago, and as soon as she started work, she managed her period as everyone else did, by using scraps of cloth from the factory floor. They call it ‘joot’. “We got it from the cleaners. They would sweep it up and give it to us. It was very itchy and I was in pain a lot,” she says. Every month, she stayed at home for one or two days. “The joot only lasted half an hour. There was leaking, discharge. But we didn’t know about reproductive health, even though we are women.”

In another smaller factory nearby, a woman named Vandana* leads me to the cutting room. Here, barefoot men run along long tables pulling bales of cloth behind them. It’s quite beautiful to watch. Vandana, the factory’s welfare officer, leads me to a bin near one of the tables. “There. That is joot.” It used to be her job to gather the joot in secret and hand it over discreetly to whoever asked for it. As in other factories that HERproject visited, discharges and infections are rampant. Every woman I speak to has regularly had discharge and health problems from using joot. Up to 10 per cent of workers are going absent. When they are asked, the factory managers – all male – know what is behind it. “One told me that he was getting requisitions to clean the sewer pipes all the time,” Huq tells me, “because they were clogged with joot.”

Most women here now use sanitary pads. A central part of HERproject is to persuade factories to buy in sanitary pads from local supplier ACI and sell them at a highly subsidised cost. In this factory’s medical centre, a basic but clean room off the factory floor, there are several boxes of pads, sold to workers for 31 taka (compared with a market price of 80–90 taka, or $1).

The compliance officer here is an intense young man. “We had real problems with absenteeism. And obviously this is a production-based factory. But even so, the general manager was embarrassed to talk about menstruation.” Now, with absenteeism down to 6 per cent, according to the factory’s records, embarrassment is redundant. Sewer pipes are no longer clogged. In another Dhaka factory, absenteeism dropped by half. A factory manager told the London Times that although she saw the programme as “just another project”, she had had to change her mind. Now the male workers are asking for a similar project for them too.

It costs around $5,000 to $7,000 to set up a HERproject, and HERproject Bangladesh is researching return on investment relating to menstrual hygiene, because persuasive figures here will help to unclog managerial blockages that still sometimes occur. The programme model requires an hour a week for the training in the first years, and not every manager is willing to take that time from the production line.

But even with rudimentary figures, a report on business returns states that managers recognise “non-quantifiable benefits of HERproject initiatives”, such as improved worker satisfaction with management and improved reputation among factory clients.

“The HERproject has also helped my relationship with the women workers,” a factory manager named Mr Riaz told the Times. “They are not so shy to talk to me anymore. If there are problems, I now hear about them.’

As I sit in a refresher course for peer educators, surrounded by young women wearing pink aprons and headscarves made from the school uniform material the factory produces, someone brings me a brown paper bag. All around me, women are talking with frankness and freshness about a taboo subject, like the schoolgirls of Tatopani. As the women discuss sexually transmitted infections, the health and hygiene of the reproductive tract, and the unquestionable value of pumpkins, I open the bag and find a sanitary pad taken from the factory’s subsidised supply. Produced in Bangladesh and branded by Savlon, its name is Freedom.

Rose George travelled to Kathmandu and western Nepal with WaterAid Nepal. Some names, marked with a *, have been changed.

This article first appeared on Mosaic and is republished here under a Creative Commons license. Mosaic is dedicated to exploring the science of life; each week, it publishes a feature on an aspect of biology or medicine that affects our lives, our health or our society. Mosaic is published by the Wellcome Trust.

Please share this post to help raise awareness of women’s menstrual hygiene.