Public debates about women’s safety in India usually focus on violence in public spaces. But there is another dimension of safety that receives far less attention: sanitation security — the ability to access clean toilets safely, privately, and reliably throughout the day. For decades, this issue has been framed primarily as a matter of dignity and gender equality. It is also a public health issue with measurable biological consequences.

One of the least discussed consequences is the possible contribution of sanitation insecurity to kidney stone disease.

Kidney stones form when minerals such as calcium, oxalate, or uric acid crystallize in concentrated urine. The most powerful modifiable risk factor for stones is low urine volume, which is largely determined by fluid intake. Clinical guidelines recommend drinking enough fluids to produce at least 2-2.5 liters of urine per day to reduce stone risk. When urine becomes concentrated, calcium and oxalate crystals are more likely to form.

Yet for millions of women in India, particularly for those working outside the home, drinking water freely has not always been practical.

Before the expansion of household toilets under the Swachh Bharat Mission, women in many parts of rural India adapted their daily routines around sanitation insecurity. Open defecation was often practised early in the morning or after dark to avoid being seen. Numerous studies documented that women frequently restricted food and water intake during the day to avoid needing to urinate when safe facilities were unavailable.

A young woman in Bangalore that I spoke........

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