In our second article about the need for a community toilets scheme in Eastbourne, Gaynor Sadlo looks at how using the toilet relates to our health, as well as some of the health / disability issues related to public toilets.
An everyday activity directly related to health
Human beings are a unique species where, as part of our culture, during infancy we are taught to control the timing of the basic biological needs of urination and defecation, the bladder and bowel systems having evolved to be purposefully activated at times when it is socially and occupationally convenient. In hunter-gatherer times, regular elimination was carried out in and absorbed by the natural environment, but urbanisation, population growth and disease control requires management of human waste on an industrial scale. Volume-related physical limits mean that toileting is the only activity of daily living where urgency of access often becomes a requirement. The bladder needs to be emptied every 2-3 hours, that is 6-7 times a day, the bowel usually once or twice a day (Bladder and Bowel Foundation 2013). Our bipedal stance and colonic biology make squatting the normal and most effective position for defecation in both genders (Rao & Isbit 2009). Squatting–type toilets have been the norm in Asian countries, but little notice is taken of this recommended posture in the West. In most western societies where the seated water closet is the norm, the task also involves the taken-for-granted skills of manipulation of clothes using both power and fine hand grips, bipedal balance, sitting and standing, perfect timing of sphincter release, cleaning which involves considerable hand strength and reach, flushing the toilet and hand-washing which itself has become a defined activity nowadays based on the science of infection control. The form and meaning of toileting is also influenced by cultural and religious traditions, which is now much more of an issue to be taken into account in our multi-cultural society. For example, the use of paper for cleaning may not be acceptable.
Females take about 1.5 minutes to urinate, men about half that time (cultural and biological reasons – anatomy, dress, menstruation, continence conditions, mobility – and the majority of older people are female). Within the tradition of gender-separated public toilets, in the UK we need twice as many female toilets (British Standard 6465 Pt 4, 2010). However, the balance is usually 50:50 or more usually 70:30 in favour of men, as urinals are smaller than cubicles (Dept of Communities and Local Govt, 2008).
The water closet toilet has developed via historical roots and customs, the earliest flushing toilets being observed at Neolithic sites, 3000 BC. They were more widely developed during Victorian times, although public toilets were then built underground, to hide them. The rapid growth of cities around the world in the 21st century provokes the need for new solutions related to sanitation and disease control, and to sustainability of the environment. Sanitation is a challenge for all governments and local councils, but Eastbourne’s situation can be put into perspective when it is realised that around 3.5 billion people worldwide have no access to a private toilet at all (http://worldtoilet.org/wto/). Historically and socially toileting has also become a very private affair, even between intimates, reflected in the design of most toilets as a tiny room for one. Different provisions are preferred by cultural groups with hygiene rituals, such as the need for a source of water for cleaning.
There is now no statutory requirement for local authorities to provide public toilets (Knight & Bichard 2011) but there are socio-economic advantages to quality public toilet provision (BTA 2007). There is evidence that suitable public toilets promote pride of place, attract visitors, increase social equity and foster inclusion (http://www.britloos.co.uk/ ). Access to suitable toilets away from home affects citizens’ health (need to eliminate waste, from health need to drink 2 litres of water daily), dignity, mood, sense of being valued, quality of life, and pleasure in going out. We need toilets in all public places, buildings, shopping centres, stations, transport vehicles, hotels, and recreation areas. More public toilets can increase the health and well-being of the community at large, through encouragement of getting out and about, and relate to sustainability, including more use of public transport (when there are good toilets at junctions). Toilets need to be clean, hygienic, safe, inclusive, private, with good handles and locks, more homely, and they need bins for incontinence pads and menstrual care. As the average age of population increases there will be many more people of both genders who might experience incontinence, which can be well managed through pads but waste facilities may not be present in all toilets, especially those for males.
The design and care of toilets reflect the policies and values of those that own them – including positioning, numbers, cleaning and servicing. Keeping toilets clean is one of the biggest and ever-present challenges, considered an unpleasant task we all seem to prefer to avoid, and it may be viewed as a menial task for low-paid workers. On another matter, families benefit from more unisex facilities, including lower toilets and baby-changing plinths. Via reviews, the newest toilet designs at Gatwick are causing considerable celebration as the best toilets people have ever experienced, and they include 2 Changing Places (see below) and clos-o-mats. However, there are still complaints about the lack of numbers of toilets in a place where many people have to queue too long, to go before boarding their plane. This is an example of how a reputation and experience of a place is very affected by its toilet provision.
Lack of public toilets contributes to unsanitary, dirty, odorous fouled streets and buildings while increasing the risk of infection, attracting vandalism, anti-social behaviour, social disorder and more costs, and can contribute to a cycle of decline in urban areas.
Health/disability issues related to public toilets
It is known that 14 million people in the UK have bladder problems (www.bladderandbowelfoundation.org/), which translates to 1 in 5 of us, or about 20,000 Eastbourne residents who might need to use public facilities more frequently and quickly. Incontinence can be exacerbated by medication taken for common health conditions (eg ‘water tablets’ for heart failure), or dementia. “Loss of continence is the greatest fear of many older people, limiting the time spent away from home and can be a major cause of never leaving home. Thus the distressing effects of incontinence causes social isolation and embarrassment for millions of people. It often becomes the primary reason for people to move into managed care environments” (Knight & Bichard 2011 p 5).
I in 10 of us have bowel problems – or around 10,000 people in Eastbourne. These figures do not take account of the many thousands of visitors to the town each year. Help the Aged (2007) found that nationally, 80% of older people find it difficult to find public toilets, 75% found them not open, and 52% of people admitted that lack of public toilets prevented them going out as often as they would like to. The World Health Organisation has cited toilet provision as a major factor in their Age Friendly Cities guides (WHO 2006). These matters are more common, but not confined to the ageing body – young ones, such as those with Irritable Bowel Syndrome (IBS), need to go to the toilet much more frequently. Lack of toilet provision is seen as a serious barrier to wider participation for many people who do not have obvious disabilities. Higher food intake and alcohol misuse, common problems in society, also drive more frequent need for toilet visits. Obesity leads to several problems in managing the toilet, such as the restricted cubicle space, clothes management and reaching to clean.
Physical disability, in particular, compounds access to toilets away from home and can be a major source of becoming housebound, inhibiting or preventing many opportunities like just getting out of the house, shopping, visiting friends, eating out, going to the pub, entertainment, and other leisure pursuits (DWP 2008; Clark & Rugg 2005). “I felt like a prisoner in my own home”. This also negatively affects the economic health of urban areas. Considering national rates, 6,500 people in Eastbourne can be expected to have a physical disability. The fact that these numbers are not very visible in the town itself is the case in point – a sign that many people with these problems may rather stay at home. The provision of a variety of toilets such as some with higher seats and rails for ambulant disabled people might encourage more outings to town, and more prosperity for all businesses.
Wheelchair-bound people might venture out much less frequently because of the additional energy needed to get around generally, such as negotiating curbs, in spite of recent enhancements in the town generally. “..we go to this ice-cream place, he loves it there, but the toilets are downstairs, its so narrow there…I cannot get him there”. Many physically disabled people need a carer present to assist, which led to the development of the first unisex toilets in the UK in the 1980’s. However, disabled peoples’ needs can be poorly understood by many while the regulatory controls which oversee disabled people’s access has not been historically strong – which was seen as a form of oppression and estrangement (Imrie & Kumar 1998), and although the situation is improving somewhat, still there is the situation of ‘ablist power’, according to a study of (In)accessible public toilets (Kitchen & Law 2001). Space is seen as socially produced, and in ways that show that disabled people are excluded from full participation in society. It has needed successive legislation to bring any kind of social justice regarding the removal of environmental barriers. “The built environment tends to perpetuate the conception that disabled people are different and ‘unable’ when their possibilities for access and mobility are restricted” (Imrie & Kumar 1998 p361). Any building with a step – and any place without an accessible toilet – acts as an effective barrier against wheelchair users – it is a form of design apartheid.
Wheelchair accessible toilet design information is now widely available and there should be more of them in all towns and buildings, although recommendations regarding design are frequently not adhered to. The need to keep them locked due to social misuse (such as sexual activity, drug use or for homeless provision) has lead to the national key scheme being a necessity. “I totally refuse to pay for a key because nobody else has to pay for a key to go to the toilet…it makes me feel bad and less than second class”. “you can understand why people would feel reticent about asking for help to go to the toilet…I don’t enjoy asking someone to help me go to the loo when it’s a normal bodily function which everyone has the right to use when and how they want”. People need to do much more planning ahead prior to visiting public places.
However, even wheelchair friendly loos do not meet all needs. Recent research carried out in Germany, where like in the UK disabled toilet provision is quite good, nevertherless highlighted the plight of mothers of disabled children (Hoppstädter et al). During interviews mothers described the terrible burden and enormous effort required of finding places to change their child – ordinary disabled toilets provide no provision for them. “Wherever you go, you never find a place to change your child if they are any bigger than a toddler…in the end one usually has to struggle trying to do it in the car…”. Plinths that do exist in baby changing toilets are suitable for only the smallest children. Many disabled children can never become continent, and therefore larger plinths are vital. We thus we can celebrate the fact that we have two Changing Places toilets in Eastbourne – in the Arndale Centre and by the Bandstand. ( www.changing-places.org/the_campaign)
There is another very serious issue related to our attitudes to helping people go to the toilet when they are sick. Increased hydration is of course linked to more frequent need to get to a toilet, and so it can easily be seen that it is tempting for staff to limit the amounts drunk, in institutions with limited staff numbers. This approach can easily lead to deaths by dehydration. There is a need to educate ourselves about our basic hydration needs, and the attitudes of staff towards patients’ toilet needs, requires radical improvement nationally. In 2013 it was reported (Sky news October 2013) that 100,000 people each year are suffering from Acute Kidney Injury in NHS hospitals. This the term used for the effect on the kidneys of dehydration. It is estimated that this kills more people per year than cancer, and costs the NHS up to £620 million per year. It seems that innate staff attitudes to helping people to the toilet, seen as an unpleasant duty, as well as lack of focus on drinking patterns may be related to this problem. There was a scandal in Eastbourne a few years ago where it was exposed that people in care homes may be expected to use incontinence products before this is personally a need, due to the lack of provision of toilets and lack of staff to attend to residents frequent toilet needs, or a desire to prevent incontinence accidents, especially at night. Thus, there needs to be more awareness of the need to drink more water everyday for health, but this must be tuned with provision to enable more toilet visits.
This article is taken from a paper written by Gaynor Sadlo, one of Inclusive Eastbourne’s Directors, as part of its Community Toilets Scheme project. You can read the entire paper by downloading a copy in PDF here.
Our next article will focus on the public toilet provision in Eastbourne and present some tried and tested solutions to the problem.