ATLANTA—It is a typical Saturday morning in downtown Atlanta. On one block, I see about a hundred people sitting on a wall and staircase across from Hurt Park, eating meals provided by community members and organizers; perhaps the only meal many will eat that day.
I walk a block up the street to find a hundred or so more people lined up on the sidewalks surrounding Woodruff Park where food, clothing, toiletries, and other essential items are given out to those who need it. People have come from all over the city to the well-known area where speakers are set up playing a mix of music and voices speaking about Black Lives Matter; Saturdays being a demonstration of Atlantan’s community and care for each other. The streets and community have responded to the increasing number of people experiencing homelessness and the heartbreak of the pandemic with persistence, love, compassion, and collaboration.
Scattered amongst the busy-ness of individuals serving and receiving resources are businesses in the heart of Georgia State University’s campus, some of which have not survived the pandemic. Of those that remain, access to the one thing that community members cannot handout is denied: clean and safe toilets.
I look at the sidewalk and note a pile of human feces 50 feet from the sole public restroom in the area. I walk the perimeter of the park and see “no public restroom” signs in almost every window. A colleague enters various businesses for a bathroom break and finds that access is even restricted for paying customers.
It becomes clear that hundreds of people are left to openly urinate and defecate or use one single-user public restroom on the corner of Woodruff Park, an automatic public facility that opens the stall door after a certain amount of time has passed. As I walk by the restroom, the smell of urine and feces spills out onto the street despite the facilities’ closed door, likely due to uncleanliness from the sheer volume of users, far exceeding the United Nations recommendation of no more than 50 users per toilet in an emergency setting, and 20 users per toilet post-emergency.
This is the reality for the millions of individuals who experience homelessness each year in the U.S. Increases in restrictions to restrooms and policies policing homelessness generally have converged to limit access to bathrooms well before the pandemic in 2020, evidenced by the multistate Hepatitis A outbreak that began in 2016 largely among people experiencing homelessness. Hepatitis A is commonly transmitted through accidental consumption of small amounts of feces, which is more likely to occur when a person must defecate in non-bathroom settings and is unable to wash their hands. Inadequate bathroom access has been exacerbated during the pandemic as restaurants, libraries, public government buildings, and shelters have closed or changed operating policies, all amidst an increase in evictions and in the number of people experiencing homelessness.
Today, on World Toilet Day, I call us to reflect on this escalating public health crisis in the U.S. as lack of sanitation adversely impacts health, and sanitation is a human right that every person deserves no matter their housing status.
Toilet access in the US
Lack of toilet and bathroom access is dehumanizing. Bathrooms are where we care for and perform some of our most intimate needs and behaviors. Obviously, we defecate and urinate. We also manage menstruation and other biological needs. We wash our hands, maybe change our clothes, and check our appearance, helping us prevent disease and gain confidence and self-esteem. We have privacy to just take a breath and be by ourselves, adding to our emotional and mental well-being and our feelings of safety and security. Bathrooms, when sufficient, provide us the space to care for ourselves and have dignity, to feel human.
In urban areas throughout the U.S., close to a million people experiencing homelessness are without access to even the most basic sanitation services. It is estimated that at least 630,000 people experiencing homelessness do not have sustained access to a flush toilet in urban areas, and at least 300,000 others rely on shared bathrooms, a concern because use of shared facilities increases the risk of diarrhea, enteric infections, and other health outcomes. During the current pandemic, shared facilities are a major concern as they can become sources of both airborne and contact exposures to SARS-CoV-2. Conversely, for many people experiencing homelessness, an inadequate shared facility may be the only option aside from the great outdoors.
The sheer existence of shared facilities is not sufficient. We must also consider:
- The number of people experiencing homelessness using each facility;
- Hours and days of operation, including seasonal access;
- Location and distribution of facilities;
- Cleanliness of facilities and available resources inside;
- Access requirements (e.g., does an individual need a key, identification, or entrance to a facility like a government building);
- The policing and other related context surrounding facilities.
Pre-pandemic (2017), prior to any public space shutdowns, the ratio of bathrooms to people experiencing homelessness was insufficient in major cities across the country. Cities with the largest numbers of people experiencing homelessness (New York City, Los Angeles, Washington D.C., among others) failed to meet either of the United Nations recommendations regarding bathroom-to-people ratios in emergency and non-emergency settings. The ratio of bathrooms to people was most egregious in New York City, with one toilet for every 105 people experiencing homelessness; and in Los Angeles, with one per every 126 people.
Menstruators experiencing homelessness have additional needs including bathroom access for changing and disposing of period products, self-cleaning, and changing clothes to maintain dignity and prevent conditions like urinary tract and yeast infections. A recent study in New York City found that public toilets did not meet the menstrual health needs of women experiencing homelessness in terms of accessibility, cleanliness, privacy, and resources. The vast majority of audited public toilets were not open overnight and sometimes access included hidden costs or location-specific permission (e.g., public bathrooms inside the subway require payment, public museum bathrooms require attendant permission).
Additionally, higher quality public toilets that offered menstrual resources were more prevalent in higher income and higher rent areas, and less common in areas with higher proportions of Latinx residents, lower educational attainment, and people living in poverty.
In addition, public urination and defecation has been criminalized across the country. Such ordinances make public urination and defecation a citable offense, resulting in fines ranging from $50 to $2,000. In some cities, fines are required to increase for repeat public urination and defecation, and in many cities prosecutors are allowed to pursue incarceration ranging from one day to six months. Unpaid fines can also result in incarceration, all because an individual simply performs a bodily function they cannot control in the only location available to them.
Data, funding, and decreased stigma
World Toilet Day is about celebrating toilets and acknowledging that 3.6 billion people live without access to adequate sanitation globally. It is about achieving the United Nations goal of water and sanitation for all by 2030. However, people experiencing homelessness in the U.S. are not even included in this estimate.
Currently, data on sanitation from the U.S. that are reported to the World Health Organization and United Nations Children’s Fund Joint Monitoring Programme do not include people experiencing homelessness. The U.S. does not collect such information, nor do they include those experiencing homelessness in estimates per (justifiable) speculation that those without stable housing struggle to access any sort of bathrooms.
In the absence of data and support at a national level, public health researchers, practitioners and advocates are left on their own with limited funds to identify solutions. We have identified the need for female-friendly toilets that should be strategically located near those experiencing homelessness, toilets that are clean, feel safe, are easy and free to access, and have needed supplies and features to promote dignity including soap, water, mirrors, and disposal bins in stalls for menstrual products. We have identified that we can no longer rely solely on businesses and the limited number of public toilets to provide what those experiencing homelessness need. We have identified the need to expand beyond relying on shelters as more and more individuals are living completely unsheltered.
We will need national support. We will need data. We will need money. We will need prioritization of this issue.
In the meantime, we need decreased stigma and acknowledgement that housing status shouldn’t determine your bathroom access. We need removal of ‘no public restroom’ policies and ordinances that punish individuals for performing a bodily function the only way they can given the (un)available resources.
We also need you! Join me in raising awareness of this issue today on World Toilet Day. Have a Twitter or Instagram account? Snap a picture of the ‘no public restroom’ signs in your neighborhood or a public toilet near you. Feel free to provide any relevant context in your tweet or Instagram post and use the hashtag #WorldToiletDay and #ToiletsforPEH. And feel free to tag @April_M_Ballard (Twitter) or the Dignity Pack Project (@DignityPack on Twitter or Instagram).
April Ballard, MPH, is a Ph.D. candidate in the Environmental Health Sciences Program at Emory University’s Laney Graduate School and Rollins School of Public Health. You can reach her at firstname.lastname@example.org or on Twitter @April_M_Ballard.
This essay is part of “Agents of Change,” an ongoing series featuring the stories, analyses and perspectives of next generation environmental health leaders who come from historically under-represented backgrounds in science and academia. Essays in the series reflect the views of the authors and not that of EHN.org or The George Washington University.
Banner photo credit: Dolores Park Works/flickr