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The role of the public toilet: Pathogen transmitter or health

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DOI: 10.1191/0143624406bt151oa

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The role of the public toilet: pathogen transmitter or health facilitator?

C Greed
BUILDING SERV ENG RES TECHNOL 2006 27: 127
DOI: 10.1191/0143624406bt151oa

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Building Serv. Eng. Res. Technol. 27,2 (2006) pp. 127 /139

The role of the public toilet: pathogen transmitter

or health facilitator?
C Greed PhD MRICS MERTPI FCIOB FRGS
Faculty of the Built Environment, University of the West of England, Bristol, UK

This paper discusses the role of public toilets, as transmitters of disease, but also
of their importance in contributing to the health and well-being of society.
Research has shown that public toilets are vital components in creating
sustainable, accessible, inclusive cities. But there is no mandatory legislation
requiring local authorities to provide them. Over 40% have been closed in the UK
in the last 10 years. The promotion of the 24 hour city, characterized by a male
youth drinking culture, along with toilet closure, has resulted in increased street
urination, creating the conditions for the spread of previously-eradicated, water-
borne diseases in city streets. Less visible, but as virulent, has been the effect of
toilet closure for women. Women, in response to lack of toilet provision, are likely
to ‘hold on’ resulting in urine (and pathogen) retention, and bladder distension
increasing the propensity for continence problems. The elderly and people with
disabilities may simply not go out for fear of there being no toilet when they need
one. Those toilets that are available may be unusable. Lack of regulation or
compulsory standards result in poor toilet design, inadequate maintenance and
management, and unhygienic conditions, resulting in the spread of MRSA and
other drug-resistant diseases. Recommendations are summarized for the provi-
sion of a spatial hierarchy of toilet provision that would both meet user needs and
reduce the chances of the public toilets acting as epicentres of germ transmis-
sion. Unless compulsory legislation, increased funding, and improved manage-
ment, maintenance and cleaning regimes are instigated, public toilet provision
will continue to be a source of disease.

1 The importance of public toilets
1.1 Introduction and contents
This paper discusses the role of the public
toilet in contributing to pathogen transmis-
sion and physical debility, but, also, poten-
tially, advancing the health of the nation.1  3
Public toilets may be defined as comprising
both traditional ‘on-street’, local authority
public toilets and ‘off-street’ toilets to which
the public has right of access, which, together,
Address for correspondence: Dr Clara Greed, Professor of
Inclusive Urban Planning, Faculty of the Built Environment,
University of the West of England, Bristol BS16 1QY, UK.
E-mail: Clara.Greed@uwe.ac.uk or ClaraGreed@aci.com
# The Chartered Institution of Building Services Engineers 2006
are better defined as ‘away from home’
toilets.4 Section 1 sets out ‘the problem’ of
what is wrong with the present nature of
public toilet provision in the UK. Section 2
summarizes the limitations of legislation and
toilet policy. Section 3 provides key recom-
mendations, arising from the author’s re-
search, on ideal provision: and thus better
hygiene and health for all.
1.2 The importance of public toilets for all: the
missing link
Research has demonstrated that public
toilet provision constitutes the vital, missing
link that would enable the creation of sus-
tainable, accessible, inclusive cities.5 If the
10.1191/0143624406bt151oa
128 The role of the public toilet
government wants people to leave their cars at
home and travel by public transport, cycle or
walk, then the provision of public toilets is
essential, especially at transport termini. Pub-
lic transport passengers, pedestrians, and
cyclists* unlike car drivers* cannot speed to
/ /
the nearest motorway service station to use the
toilet when they find the local public toilets
have been closed. It should not be assumed
that only a minority will need on-street public
toilets, because alternative off-street toilet
options are readily available. Members of
the public are not automatically entitled or
able to use the toilets in public houses, bars,
and fast food restaurants. Access may be
restricted to customers only and children
may be barred from licensed premises. Min-
ority and religious groups may be wary of
using toilets in premises where alcohol or non-
halal food is served.6
Women are particularly in need of public
toilets as they are the ones who are out and
about in the day time, travelling on
public transport more than men, and often
accompanied by children or by elderly and
disabled relatives.7 Surveys have shown that 1
in 4 of European women between 35 and 70
years of age suffer some degree of urinary
stress incontinence which restricts their will-
ingness to travel, but only a third have sought
medical help.8 Yet, there is less public provi-
sion for women than men in many cities.
Accessible toilets must be provided under the
Disability Discrimination Act 1995 (DDA)
but this does not, necessarily, mean that
everyone’s toilet needs are now being met.9,10
Ordinary toilets may prove inaccessible for
women with pushchairs, those with luggage,
the pregnant and the elderly, because of
narrow entrances, small cubicles, turnstiles
and step access.11
1.3 Street urination: an unsanitary solution
Government policies to promote the eve-
ning economy, the 24 hour city, tourism and
public transport use, have all increased the
need for toilets, whilst, paradoxically, provi-
sion is being cut back. The proliferation of
bars, clubs and pubs (public houses) in city
centres has resulted in increased alcohol con-
sumption, typified by a binge drinking, male,
youth culture:12 and street urination. The lack
of public toilets, along with crumbling sew-
erage systems and neglect of drainage issues, is
resulting in the spread of Cryptosporidium
parvum. C. parvum (a parasitic protozoa) is
the fourth most commonly identified cause
of gastro-enteritis and thus diarrhoea.13 His-
toric water-borne diseases, such as cholera,
typhoid and dysentery, that were prevalent in
the nineteenth century, have returned to the
city streets.14,15
1.4 Public toilets: unsanitary facilities
One of the main means of transmission of
many classic diseases and many urinary,
vaginal and anal infections is from human
faeces; therefore it is extremely important
to provide adequate, hygienic public toilets.
Hospital toilets, rather than public toilets,
have received greater media interest in recent
years. MRSA in hospitals has been attributed
to lack of basic hygiene, and, in particular, to
the role of dirty hospital toilets as transmitters
of disease.16 Campaigns to encourage people
to wash their hands after using the toilet have
been introduced, along with improved toilet
cleaning regimes. The contracting out of
cleaning and maintenance services along
with the privatization of many health, welfare
and local authority functions has led to
reduced in-house control over cleaning stan-
dards. But, CA-MRSA (Community-Ac-
quired MRSA) bacterial strains found in
public toilets may prove far more serious.17
In public toilets, complete strangers mix
and use the same sanitary facilities, with all
the related risks of bodily fluid exchange,
contamination and organism transmission.
Desylpere18 has demonstrated that the chances
of pathogen transmission are very high even in
toilets that may appear to look clean, as every
door handle (especially the last one out to the
street), tap, lever, flush, lock, bar of soap, toilet

roll holder, and turnstile, is a potential germ
carrier. Ostensibly, hygienic equipment, such as
electric hand-driers (often imagined to be safer
than towels) may blow germs back into the
atmosphere. Their use can contribute to the
spread of Legionnaire’s disease, which is trans-
mitted through contaminated air.19 Flushing
the toilet can also result in mini-droplets of
contaminated air passing into the respiratory
system.18
Fears about catching ‘new diseases’ such as
SARS (Severe Acute Respiratory Syndrome)
figure strongly in the public mind.20,21 Fear of
catching exotic diseases, such as Ebola, are
expressed by passengers using airport toilets.
The prevalence of E. coli (Escherichia coli
0157), in Britain and internationally, has led
to a renewed concern with food hygiene and
also with toilet hygiene. E. coli can be
transmitted through food, by sewage, infected
water, faeces, and from person to person by
touch.22
1.5 The debilitating effect of poor toilet
provision and design
Research has shown that referrals for uri-
nary tract infections, problems of distended
bladders, and a range of other uro-gyneco-
logical problems have increased proportio-
nately to toilet closure.23 The chances of
streptococcal toxic shock syndrome from
sanitary protection is increased if there are
no toilets available to change tampons.19,24
Changing facilities are also needed by men
and women suffering urinary and anal/faecal
incontinence.25 Absolutely hygienic condi-
tions are needed for changing colostomy
bags (for faecal waste) along with good light-
ing, shelves to put equipment on, and hot
water supply.26 Public toilets may also offer
baby changing facilities, another activity re-
quiring cleanliness both for the baby and
mother, requiring adequate washing facilities
and disposal bins to ensure that subsequent
users are not confronted with unsanitary
conditions.
C Greed 129
Women need to sit down to use the toilet (at
least in the West) but have difficulty doing so
because of narrow cubicle design, whilst the
positioning of the sanitary disposal bin or
jumbo-sized, toilet roll holder may restrict
sitting space. Women are also concerned about
‘catching germs from the toilet seat’.27 Both
men and women view toilets as sites of crime,
dirt, disease, sex and disorder.28 Studies have
long shown that around 80% of women
‘hover’ over the seat to urinate when in public
toilets, whereas they prefer to sit when using
their toilet at home. Hovering contributes to
residual urine retention, as the bladder cannot
empty properly and thus to the development
of continence problems.29,30 Research has
found that crouching (squatting) reduces urine
flow by 21% and increases by 150% the
chances of residual urine remaining in the
bladder.31
2 Regulatory and legal context
2.1 Lack of mandatory requirements
Public toilet provision is governed by the 1936
Public Heath Act which gives local authorities
permissive, rather than mandatory, powers to
provide public toilets. Section 87, sub Section
3 gives local authorities the right to build and
run on street ‘public conveniences’ and to
charge such fees as they think fit ‘other than
for urinals’. If local authorities do choose to
provide toilets then these are subject to British
Standard 6465 requirements, along with
Part G of the Building Regulations entitled
‘Hygiene’.32 The standards have also been
much criticized as being minimal, discrimina-
tory towards women, not retrospective, weakly
enforced. Disabled toilet provision is subject
to Part ‘M’ of the Building Regulations,33
along with British Standard BS8300 on dis-
abled access,34 which provide a more enligh-
tened set of standards. BS6465 Part 1 has
recently been revised to include higher stan-
dards of provision, and is awaiting final
publication.35
130 The role of the public toilet
2.2 Lack of monitoring
Once built there is no legal requirement for
public toilet provision to be monitored. For
a relatively short period the Audit Commis-
sion undertook basic quantitative assess-
ment of provision (1998 2001).36,37 There is
/ for a more favourable planning permission.2
no requirement to assess hygiene standards.
Pathogen transmission could be measured by
monitoring levels of hygiene and incidence
of infection (for example by taking swabs
from toilet seats and other fixtures) as is
commonplace when Infection Control Teams
monitor hospital premises.19 Some enligh-
tened local authorities do monitor toilet
hygiene and implement strict measures to
control infection transmission, and keep
records of how often toilets are cleaned. But,
nationally the situation is extremely variable,
and many toilet providers appear to have great
difficulty even implementing the most rudi-
mentary cleaning regimes.
2.3 Lack of strategic planning powers
Local authorities have inherited a miscel-
lany of toilets built at different times to meet
changing needs. Few local authorities have a
toilet strategy or plan, and there is little
awareness of levels of need in different loca-
tions. Toilet planning is mainly concerned with
rationalizing and reducing the number of
toilets available. One local authority put its
toilets into three categories, strategic toilet
locations (on main roads and in central areas);
tourist areas; and local district toilets. Under
its cost-cutting rationalization process the
local ones were being closed, as they were
seen as the least important.1 Yet, local facil-
ities are particularly important to the elderly
and those without cars.
Under the Planning and Compulsory Pur-
chase Act 2004 emphasis is to be put upon
creating sustainable cities, and upon diversity
and equality issues within society. But there is
no requirement that public toilets must be
included in town planning policy documents
or development plans.38 Toilet provision is a
matter that is considered outside the remit of
statutory planning. Some local planning
authorities do succeed in getting toilet provi-
sion through ‘planning gain’ whereby the
developer enters into a Section 106 agreement
to deliver ‘community benefits’ in exchange
In contrast in Japan public toilet provision
is dealt with as a high-level policy issue with-
in city planning departments.39
2.4 Lack of links with health and hygiene
Toilets are not accorded the level of atten-
tion given to other front-line, health-related
facilities such as hospitals, health centres and
local clinics in terms of disease control. Rather
toilets are the responsibility of operational,
technical departments in a local authority,
such as ‘parks and gardens’, or ‘street cleans-
ing’. Seldom do departments responsible
for the running of public toilets operate in
response to longer-term policy objectives
which takes into account user needs. Most
authorities do not produce any written poli-
cies, location maps, or surveys on toilet
provision.1 A technically-orientated ‘fire fight-
ing’ approach prevails which responds quickly
to problems of vandalism and disrepair,
often by simply closing down the toilets and
thus ‘solving’ the problem to the inconveni-
ence of bona fide users.
Toilet cleaning services are generally oper-
ated by outside agencies, with little liaison
with the technical departments responsible for
toilet construction and maintenance, or
with those concerned with public health and
hygiene matters.40 Cleaning staff should be
seen as the front-line troops in disease control,
but cleaning is a low status, poorly-paid area
of employment. Cleaners need to be recog-
nized, trained and respected as the front-line
troops in preventing infection.41 Bodily ex-
creta, spit, mucus, blood, urine, all need to be
cleaned up, especially faecal remains which are
one of the main sources of pathogen transmis-
sion. Dirty toilets (and un-emptied sanitary
waste bins) attract flies, and also lice, rats,

mice, fleas, and ticks: vectors that spread
disease.42
3 Toilet provision recommendations
3.1 A spatial toilet strategy
It is vital to adopt a high-level strategic policy
approach to toilet issues, to replace the present
fragmented and ineffective situation. The
development of a hierarchy of toilet provision
would enable facilities to be targeted to area
need.43 Both spatial (geographical location)
and temporal (patterns and peaks of usage)
considerations need to be taken into account
in developing a hierarchy of provision to cover
the whole city, see Figure 1.
The central area is the main focus of the
city’s business and retail activities, and the
part of the city that tourists are likely to
visit.44 Historically the main transport routes
radiate out from the city centre, downtown
railway and bus stations being the main gate-
ways to the rest of the city. It is recommended
that toilets should be provided in all city
centres and transport termini, including at
least one 24 hour facility. In such downtown
locations, a comprehensive range of toilet
facilities might be provided in toilet ‘super
blocks’. At the district and local neighbour-
hood level less facilities are needed, but
provision should be linked to needs generated
by local shopping centres, car parks and
transport termini. A combination of local
pubs, hot food ‘takeaways’, clubs, pubs, taxi
ranks and bus stops, results in a potential
‘toilet hotspot’, see Figure 2. In smaller
settlements, rural areas and outlying suburbs,
some toilet blocks should be provided to
ensure coverage.
A thorough survey should be undertaken of
all locations, and likely user needs identified.
Plan-making has three stages, namely, SAP  / Clear footpath links should be ensured
Survey - Analysis - Plan. Applying this
/ /
approach to the development of toilet policy,
the toilet planner needs to ‘survey’ the existing
situation of the area, identify problems, note
C Greed 131
lack of facilities, and estimate future demand
trends. Undertaking this exercise in a rational
manner would reveal the extent of the problem
and the pent-up demand for public toilets.
3.2 Levels of provision
At minimum, it is recommended that ‘a
local authority should provide no fewer than
one cubicle per 500 women and female
children and one cubicle or one urinal per
1100 men, and no fewer than one unisex
cubicle for use for people with disabilities
per 10 000 population and no fewer than
one unisex nappy changing facility per
10 000 people dwelling in the area.’45 The
relevant ‘population’ in question should in-
clude commuters, tourists and visitors as well
as residents.
3.3 Temporal factors
A distinction needs to be made between
locations where there is an ‘interval’ when
large numbers of people need to use the toilet
within a short space of time, for example in
theatres and sports stadia, as against locations
where usage is more gradual throughout the
day, such as in a library or museum35 Differ-
ences between days also need to be taken into
account; Saturdays, school half-terms and the
shopping days before Christmas are likely to
be generate long queues for women’s toilets.
3.4 Detailed siting considerations
In deciding where to put the toilet thorough
site appraisal should be carried out using all
the skills of urban design. Many well-designed
toilets have been placed in a bad location only
to be trashed by vandals, especially if hidden
from view behind bushes. Toilets should be
proudly placed in central public thoroughfares
and squares, in open well-lit areas as valuable
townscape elements.46
from toilets to coach pick-up points, bus
stops, pedestrian crossings, and car parking.
Increased foot flow past the toilets is likely
to reduce loitering and increases natural
132 The role of the public toilet

Out of Town
development
location

Suburban housing
‘Anywheresville’
location

City Centre,
main transport
termini location

Commuter village
location

Toilets
Motorway arterial road
and ring road location

Figure 1 City-wide hierarchy of toilet provision (Source: Inclusive urban design: public toilets2)

surveillance. People ought to be able readily 3.5 Toilet access

to find toilets where they traditionally and
intuitively expect them to be located. There
should be adequate signage showing where the
toilets are and where they are located. Open-
ing hours should be shown along with the
location of the nearest 24 hour facilities, see
Figure 3.
Toilets should not be located on steep
slopes, or rendered inaccessible by steps,
but, ideally, should be positioned at street
level. Handrails and gentle steps should
also be provided as well, for those who
cannot cope with ramps, such as people
with arthritis. The area around the toilet
 C Greed 133

Explanation: This is a condensed

diagrammatic sketch of a district
centre, which comprises one cell in
the structure of the city.

Principle: Adequate toilets should

be provided for each different user
group, for example not everyone can
or wants to go into a pub, and there
should be adequate toilets for both
public transport users and car users.

Toilets in every bus station

and major district bus stop,
Toilets in every car park
over 50 car parking spaces

Although there is a pub nearby Toilets in every

public toilets for shoppers needed market place, town
along the main shopping street square and centre

Toilets in every park

prominently placed
facing on to main road

Figure 2 District-level principles of toilet provision (Source: Inclusive urban design: public toilets2)

should be free from clutter. Recycling skips
should not be placed alongside toilets, adding
to the insalubrious, unhygienic image of the
public toilet. Toilet block location should take
into account local micro-climatic conditions
to increase user safety. Frosty hollows and
windswept sites should be avoided, in favour
of sites open to the sunlight and good air
circulation. In hotter climates, toilets need to
be well ventilated and shaded from direct
sunlight.
3.6 Internal design
It is not the purpose of this paper to detail
internal design considerations (see Greed2)
but as a general principle, any toilet block
134 The role of the public toilet
Table 1 Toilet location priorities
A toilet strategy, an overall plan setting out the hierarchy,
location and distribution of public toilets should be
provided for every local authority as part of mainstream
urban policy.
Public toilets should be provided in:
. All main public transport termini and stations and
major car parks
. Central areas, and in all district centres, and local
shopping centres
. All parks, allotments, urban farms and leisure areas
. At main junctions and by post offices in all suburban areas
. Out of town developments in office, industrial and
retail parks
. In all villages over 5000 in population and at reason-
able distances along main roads
. User consultation and public participation should
shape toilet policy making
. In summary toilet ‘hotspots’ should be identified and
concentrated upon.
provision should be adequate for both women
and men, as illustrated by Figure 4. The size of
cubicles, location of sanitary bin and toilet
roll, distance between the edge of the door and
toilet pan, all need to be thought through
carefully as these ‘small’ factors determine a
toilet’s accessibility.26,47 It is recommended
that a 250 mm clearance is maintained right
around the toilet seat, so doors do not
impinge on the rim of the toilet bowl, and,
ideally, sanitary disposal facilities are ducted
into the back wall of the cubicle.
3.7 Cleaning and hygiene
Once built toilets cannot be left alone to
look after themselves. The initial capital costs
of toilet construction and equipment may only
account for 20% of the total toilet cost over 5
years; running costs are considerable. Good
design must be complemented by efficient
maintenance and regular cleaning regimes.
As Mary Schramm, a leading expert in clean-
ing science has stated, ‘architects never think
about the problems trying to clean the build-
ings they design’.41 Cleaning considerations
should figure prominently in the development
of the local authority’s total toilet strategy.
Liaison and communication needs to take

Part of the Main

Public Market Place

X GENTS

X
MULTI-USER
LADIES

Keep trees away from toilets,

do not screen them
Attendant Avoid fences and
Essential walls that reduce
visibility

X Clear direction to bus

routes, connecting routes
and ‘way out’

No steps! Access
should be at grade
or use ramp

Lots of circulation space,

lots of visibility

Figure 3 Local toilet siting principles (Source: Inclusive urban design: public toilets2)
 C Greed 135

Figure 4 A 2:1 ratio of toilet provision in favour of women in a toilet palace

Key:
1. PAMIS size adult changing toilet.
2. Disabled unisex toilet nearest the Gents.
3. Unisex changing area for babies or those who need more space.
4. Baby feeding and changing area.
5. Attendant’s room.
6. Storage for pushchairs, luggage, etc.
7. Children’s toilets.
8. Supervised entrance (but not barrier pay system).
9. All night unisex and uni-able toilet on outside of building with CCTV nearby.
10. Disabled unisex toilet nearest the Ladies.
(Source: Inclusive urban design: public toilets2)

place between toilet-providers, manufacturers,
and designers; and cleaning experts, health
and caring experts in order to meet user needs
in a salubrious manner.
To reduce germ transmission toilet users
must wash their hands. Soap might best be
dispensed in automatic dispensers that do not
require the user to touch the mechanism. If
bars of soap are provided they should be put
in receptacles that facilitate drainage, so the
user is not confronted with a soggy, germ-
infested mess. Paper towels create waste and
are inefficient. To reduce the risk of Legion-
naire’s disease, traditional roller towels are to
be preferred to electric dryer systems: pro-
vided the roller is kept in good repair and the
towels are frequently replaced.
It is recommended that touch-free flushes,
taps, and door opening devices be provided to
reduce cross-contamination. Such high-tech
gadgets are vulnerable to vandalism. Having
invested in such equipment it is more cost-
effective to provide on-site toilet attendants as
their presence reduces anti-social behaviour.
136 The role of the public toilet
Wage costs will be recouped by reductions in
toilet damage.1
4 Concluding comments: what needs to
be done
4.1 Mandatory legislation
This paper has highlighted the role of public
toilets in both the spread of disease and in
generating well-being. The government is tak-
ing a huge risk with the nation’s health in not
paying attention to public toilet provision.
Therefore, it is recommended that an Act of
Parliament needs to be introduced to make
public toilet provision by local authorities
compulsory. Better minimum standards of
provision are also required than currently
provided by British Standards and related
Building Regulations.
This paper has highlighted the negative
effects of under-provision on female users.
As a member of the European Union (EU)
the United Kingdom is now required to take
equalities issues into account in all aspects and
at all levels of government. A new Equality
Act which will come into force in December
2006 will put a duty of gender equality upon
the public sector in respect of all aspect of
policy development, design and delivery of
services.48 Likewise, a more inclusive approach
needs to be adopted to meet the needs of all
those with disabilities, along with all who are
dis-enabled by inadequate toilet provision,
including the elderly, pregnant, parents with
small children and those who are carers.
Better public toilet provision should not
be seen as a drain on resources. Surveys by
the Association of Town Centre Managers
have demonstrated ‘the business case’, show-
ing that that better public toilet provision
increases local business, shopping turnover,
and tourist numbers.49 Better, cleaner toilet
provision would also undoubtedly reduce the
amount of money spent by the National
Health Service (NHS) on urological and
incontinence services50 and, arguably, contri-
GOLDEN TRIANGLE OF TOILET
PROVISION
Hardware
Design
Education Maintenance
Figure 5 The ‘Golden Triangle of Toilet Provision’
(Source: Singapore Toilet Association and Inclusive
urban design: public toilets2)
bute to the reduction in the transmission of a
wide range of viruses, germs and diseases,
which, if left unchecked, might claim many
more lives.
In order to undertake an effective pro-
gramme of toilet provision, re-instatement
and upgrading, toilet policy needs to be put
in the hands of strategic spatial policy makers
within local authorities. The implementation,
maintenance and day-to-day management of
toilet facilities need to be adequately funded,
and properly monitored and supervised by
technical departments. An integrated rather
than fragmented approach to toilet provision
and management needs to be introduced.51
Departments, agencies and professionals who
are concerned with citizens’ health and well-
being need to have a major input in toilet
decision-making: these might include repre-
sentatives concerned with childcare, the
elderly, disabled, education, public health,
local health services, clinical medicine, and
user group needs. This would ensure that a
user-perspective, along with a more social
and medical outlook, was mainstreamed into
toilet policy-making. This would also create a
‘culture change’, among toilet providers, ‘a
culture of cleanliness and care’ resulting in
better more accessible provision for everyone.

After all, availability of free and unrestricted
use of the toilet remains one of the most basic
requirements for good health and regular
habits.
References
1 Greed C, Daniels I. User and provider
perspectives on public toilet provision . Based on
Nuffield Trust funded research of the same
title, Occasional Paper, Faculty of the Built
Environment, University of the West of
England, Bristol, 2002.
2 Greed C. Public toilets: inclusive urban design.
Oxford: Architectural Press, Elsevier
Publications, 2003.
3 Hanson J, Greed C, Bichard J. Inclusive design
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