​Squirm-inducing facts of life like diarrhea, tapeworms, and other water, sanitation, and hygiene (WASH) ailments are part and parcel of one’s typical foray into health issues of the developing world, yet one hygiene-related phenomenon has received a surprising amount of attention from donors over the past decade: periods. With the countless number of euphemisms we’ve generated in the English language to refer to ladies’ “time of the month,” most people are inclined to politely veil the crimson tide’s existence. However, the circulation of a staggering 2005 World Bank estimate —that young women lacking access to feminine hygiene products in the developing world may be missing up to 20 percent of their education— seems to have caused a shift in that paradigm in recent international development discourse.

As the story goes, young women are missing up to one-fifth of their education because they lack access to modern sanitary products. Often left with soaked-through reusable pads, limited or no access to running water, or no menstrual hygiene management (MHM) resources at all, these girls face the difficult choice of braving school with stained clothing, using unhygienic and uncomfortable rags, or staying at home. This situation—further exacerbated in some contexts by cultural and religious taboos related to menstruation—is thought to lead to higher absenteeism, course failure, and, ultimately, dropout rates for young women in the developing world. In fact, some NGOs like Femme International have argued that periods are the “number one reason that girls miss school.”[1] Given that educational outcomes are tied to a wide variety of other indicators of social and economic progress, the effect of these estimates on development outcomes could be enormous if they are true.

As well-intentioned corporate philanthropists and nongovernmental organizations are wont to do, the release of these claims resulted in an outpouring of funds dedicated to financing eco-friendly sanitary products and providing MHM education to girls in the developing world. Campaigns such as the Procter & Gamble “Protecting Futures” program and commitments from prominent NGOs and the Clinton Global Initiative developed in earnest.[2] After all, the solution seemed so simple: if gender-based educational disparities are rooted in the fact that girls merely don’t have access to the proper MHM resources, then their provision could hypothetically be the silver bullet solution. 

The unfortunate reality is that there are rarely any such slam-dunks in international development, and this appears to be no exception. Although eliminating gender-based disparities in education outcomes has been a focus of aid donors since the advent of the Millennium Development Goals, a few notable actors have questioned whether the inaccessibility of appropriate sanitary products is the true culprit of absenteeism. Esther Duflo, Director of the Abdul Latif Jameel Poverty Action Lab (J-PAL), for example, has argued that absentee rates are the same for boys and girls in much of Africa, and that “What’s keeping children from school is the costs of attending”—not periods.[3]

To gauge whether the anecdotal evidence regarding female absenteeism was supported by investigative scrutiny, J-PAL affiliates designed an impact evaluation that distributed reusable menstrual cups to girls in the seventh and eighth grades in Chitwan, Nepal. The evaluation was designed to test whether menstruation indeed served as a barrier to female education, and whether the provision of modern sanitary products would increase attendance and school performance among girls.[4]

The results of the study indicated that the menstrual cup intervention did not have its intended impact: researchers found that girls only missed half a day of school per year, on average, due to their periods. While the intervention had some positive impacts—the girls in the treatment group overwhelmingly chose to use the cup and continued to do so over time—it was not shown to reduce the small amount of school missed due to menstruation, nor was it associated with an increase in test scores. Moreover, 44% of girls in the study reported that while the cup did help manage menstrual blood, they typically missed school because of the cramps they got while on their periods—not necessarily because of stains or embarrassment.[5] As the researchers concluded, “the underlying causes of low school attendance for girls are complex, and … the relatively easy solution of providing sanitary products may not result in the educational gains policymakers had hoped for.”[6]

Randomized controlled trials (RCTs) such as this one are generally considered to be the gold standard for scientifically gauging the efficacy of interventions While anecdotal evidence is certainly valuable, RCTs are designed to examine the relationship between intervention and impact with greater accuracy. Nevertheless, it remains prudent to question the extent to which RCT findings should be universalized, particularly when they address complex cultural issues like periods. Menstrual taboos are pervasive throughout the world and interact with different social and spiritual norms depending on the cultural context. In western Nepal, for example, the tradition of Chhaupadi isolation requires women to live in a shed outside of the home for the duration of their periods. This raises a common question related to RCTs: to what degree might the findings of a study conducted in Nepal have cross-cultural applicability? Faith Macharia, the National Director of the Forum for African Women Educationalists in Kenya, has argued that they do not: “Girls will stay home rather than be embarrassed,” she said, citing studies conducted by her organization that support the period-absenteeism connection.[7] What, then, should one believe?

Social issues related to gender equity and female inclusion are complex and, unfortunately, are unlikely to be solved with a one-size-fits-all solution. This debate demonstrates that while social scientific evaluations like RCTs are undoubtedly useful, it is important to question their external validity: data certainly matters, but culture matters, too.
 
Sydney Taylor is a Master’s candidate in Global Policy Studies at the LBJ School of Public Affairs at The University of Texas at Austin.

[1] “Menstruation, Development & Women’s Rights,” Femme International, 2013, http://www.femmeinternational.org/the-issue.html.
[2] Claudia H. Deutsch, “A Not-So-Simple Plan to Keep African Girls in School,” The New York Times, Nov. 12, 2007, http://www.nytimes.com/2007/11/12/giving/12GIRLS.html.
[3] Ibid.
[4] “Menstruation as a Barrier to Education?” Abdul Latif Jameel Poverty Action Lab, June 2011, https://www.povertyactionlab.org/sites/default/files/publications/Menstruation%20as%20a%20barrier%20to%20education.pdf.
[5] “Menstruation and Education in Nepal,” Abdul Latif Jameel Poverty Action Lab, 2011, https://www.povertyactionlab.org/evaluation/menstruation-and-education-nepal.
[6] “Menstruation as a Barrier to Education?” op. cit. 
[7] Deutsch, op. cit.

The conversation was dynamic and touched upon several threats to our global threats. While the discussion centered upon making predictions of what threatens us in the future, Will Inboden began with a countering caveat – we are typically bad at making predictions. He referenced Professor Norman Angel’s The Great Illusion written in 1910 that argued we have reached an age where war is futile and states therefore won’t fight. Angel was not a lone wolf in believing this; many preached this alongside him. Unfortunately, just five years later the bloodiest and deadliest war that mankind ever witnessed broke out. The moral of the story? Predictions aren’t always right.
 
His point in sharing this with us was not to belittle the topic of the conversation but rather to reinforce that we must do less predicting and more preparing. With that in mind, he presented three categories of states which must be on our radar in order to be adequately prepared. Policy makers should think about these three categories and be prepare to respond to each.

• Strong States: This category includes countries such as Russia and China that have incredible land masses, large economies – your traditional great powers that have potential to disrupt the status quo or distribution of power and resources.
• Weak States: Here you will find Libya, Syria, and Iraq. These states are characterized by fragile or poor governance, a lack of monopoly over force, and tend to serve as vehicles for terrorism, civil wars, or other dangerous pathologies.
• Malignant States: The North Korea and Iran of the world – countries whose governments are strong enough to secure their borders and acquire a monopoly of force but lack economic influence. Despite this unbalance, they do have the means to create regional instability through unpredictable behavior.

 
Kate Weaver then shifted the conversation from your typical associations of global security, (terrorism, war, intelligence) to a topic whose connection to insecurity and conflict is often overlooked – food security. Food security is determined by a person’s access and availability to nutrition. As many as 795 million people across the world suffer from food insecurity. This comes downs to 1 in 9 globally, and heightens to 1 in 4 in Sub-Saharan Africa, disproportionately targeting children. In countries of conflict like the Central African Republic or Syria, food is a weapon on war and starvation is the cruel infliction of pain. And the United States is not immune. We at home face the issue of hunger with 1 in 7 of our citizens qualifying as food insecure. In addition to this direct within-our-own-borders effect, we are impacted by other countries food security as well – especially those which we have geopolitical concerns over such as Ira, Liberia, Afghanistan. If we believe that “hunger anwhere threatens peace everywhere” the state of food security in the world is no doubt concern for global stability in the future.
 
So learning from Inboden, how do we prepare for this? Food security is an issue that can not be solved by aid alone (Sorry, Jeffery Sachs) While SDG#2 may call for the end of rural hunger by 2030, the issue can not be approached in policy isolation as it exists within a web of social constructions that will help or hinder its eradication. It must be integrated into poverty alleviation approach holistically.
 
And so, Kate left us with three bits of food for thought.

1. Harness the power of bioengineering mechanisms.
2. Mobilize political will on the issue of food security as the issue is not a natural disaster but a man-made phenomenon. We need to reach consensuses on trade that will open markets and increase access.
3. Take preventative steps that will build resiliency in food insecure countries to combat exogenous shocks when they occur.