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Here's something teenage girls in well-off countries take for granted. When they get their periods, there's no shortage of products such as tampons or pads, no reason not to carry on with school or sports. But for tens of millions of girls in low-income countries, these products are unaffordable. NPR's Nurith Aizenman reports there's a growing effort to address the problem, starting with getting people to talk about it.
NURITH AIZENMAN, BYLINE: Elynn Walters works for a group called Wash Advocates. They're trying to make menstrual hygiene a global priority. And when she meets with high-up officials of international health organizations and governments, she likes to start off with this ice breaker.
ELYNN WALTER: We'll say, OK, everyone stand up and yell the word, blood. Or stand up and say, you know, yeah, half of the people in the world have their period.
AIZENMAN: You literally do that in a meeting?
WALTER: I do.
AIZENMAN: She says she does this because there's a lot of squeamishness around menstrual hygiene. And this squeamishness isn't just a silly distraction. She thinks it's a big reason global health advocates ignored the topic for decades.
WALTER: It's not that it wasn't an issue, but it was just one of those things that no one was talking about.
AIZENMAN: But things have begun to change. Over the last several years, a growing number of researchers have started looking at the impact of this issue on girls' lives. Marni Sommer was one of the first.
MARNI SOMMER: Try doing your Ph.D. on menstruation and sitting at a dinner table when people say, so what's your dissertation on?
AIZENMAN: Sommer is now a professor at Columbia University's School of Public Health. Her work aims to answer a question that's nagged at her ever since she was a Peace Corps volunteer in Eritrea.
SOMMER: A lot of girls were disappearing from school around puberty.
AIZENMAN: So once she got to grad school...
SOMMER: I started looking at the literature, trying to understand why do we still have this gap in schooling between girls and boys in lower-income regions of the world.
AIZENMAN: There were a range of explanations, but no one seemed to be paying attention to an obvious one. For girls, puberty means getting your period. And Sommer remembered that the schools in Eritrea that she had seen weren't exactly equipped for that. They didn't have toilets or running water.
SOMMER: I wondered how would I, at age 10, 12, 14, 16, have sat in a classroom for six hours a day with boys squished under the same desks as me. Would I have come to school because I went to an all-girls school, and I still worried about standing up in class and having accidents on my skirt.
AIZENMAN: Studies have now been done across Africa and parts of Asia and Latin America. And so far, they all suggest the same thing. This problem is severe enough that girls are missing school every month. Sommer says part of the solution is to build toilets in schools - private ones with doors that close, water to wash your hands. According to UNICEF, more than half of schools in the lowest income countries don't have latrines like this. Elynn Walters, the advocate with Wash, says another urgent need is leak-proof products. Those maxi pads so many girls in well-off countries rely on can cost about $2 a piece.
WALTER: Populations that live on less than a dollar a day can't afford that. They can barely afford school fees, let alone menstrual products.
AIZENMAN: The good news - a flurry of nonprofit and for-profit companies are jumping in to develop low-cost options. In rural India, women's self-help groups are buying semi-automated machines that let them make 200 to 250 pads a day. In Rwanda, a company called SHE Enterprises is training women to make them out of banana-trunk fibers. In Uganda, a company called AFRIpads has already produced enough washable, reusable pads for 500,000 girls across Africa. At a recent gathering of menstrual hygiene advocates in Washington, I come upon the latest entrant to the market. It's underwear, bright purple with a waterproof bottom.
DIANA SIERRA: It feels like fabric. It's not plasticy.
AIZENMAN: That's Diana Sierra, founder of the company called BeGirl. She explains that the underwear is reusable and comes with a mesh pocket that girls can fill with whatever absorbent material they can find.
SIERRA: You can stuff anything, so you go kind of a MacGyver-style. Just stuff it with anything that is safe that you can find around.
AIZENMAN: Sierra's a Columbian-born industrial designer who worked for a number of global companies. She came up with her product after she went back for master's and did an internship in Uganda, where some girls confided in her about the problem. She says this is something we can fix.
SIERRA: We're not talking about rocket ships. We're talking about sanitary pads. Yet, they both have the same effect. They take you places.
AIZENMAN: Nurith Aizenman, NPR News.
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