In June 2017, Homeless Healthcare Los Angeles (HHCLA), a nonprofit community organization, found that only nine public toilets were available for over 1,700 people who were living homeless in the Skid Row district of Los Angeles. Knowing this constituted a public health crisis and a denial of human rights, HHCLA opened the ReFresh Spot in 2018.

“The community had been wanting more access to resources for over a decade,” said Stephany Campos, executive administrator at HHCLA, during a presentation about her work at the Reform conference in St. Louis this month. “When the ReFresh spot came to fruition, that was the first time permitted public toilets were brought to the area, which is astounding. People need to use the restroom outside of business hours.”

ReFresh Spot now serves 600 guests a day, providing them with restrooms, showers and laundry services 24 hours a day, seven days a week.

HHCLA’s emphasis on access to basic sanitation reflects that harm reduction has imperatives far beyond the facilitation of safer drug use. The organization’s continuum of harm reduction services also includes wound care, naloxone distribution and training, and syringe exchange—to name but a few.

“There’s no barriers to entry here,” Campos said. “You don’t have to give up your name or sign up to use the bathroom. There’s a very low threshold, and that speaks to the success of the site. We can walk people to our other harm reduction center if they need something more, and they can receive naloxone. We listen to our guests and what their needs are.”

When HHCLA first studied the Skid Row area in 2017, it found that public toilets were so scarce that the city violated United Nations sanitation standards. At night, the neighborhood had 80 fewer toilets than the UN standard demands, and by day, when the homeless population swells, it was 164 toilets short. In September that year, the neighborhood saw an outbreak of hepatitis A; city officials identified the cause as unsanitary conditions due to lack of toilets.

The effects on people’s cleanliness and physical appearance can make it more difficult to get or keep a job or a home.

The quality of toilets available was also woefully inadequate. Restrooms were closed during hours when they were supposed to be open. Many were poorly maintained, with broken doors, waste and debris. Or they lacked basic amenities like toilet paper, sinks, soap and baby stations. Very few toilets were accessible to people with disabilities.

The lack of adequate facilities has had many health and social consequences for Skid Row’s homeless population. Most obviously, people without toilets face the danger and humiliation of urinating or defecating in public. Poor hand and body hygiene can transmit illness or infections. And the effects on people’s cleanliness and physical appearance can make it more difficult to get or keep a job or a home.

Lack of public toilets also makes homeless people a target of police and criminal penalties. In New York City, for example, police issued over 300,000 summonses for public urination between 2006 to 2016. In 2016, the city decriminalized the act and made it a civil offense, but people are still subject to citations and fines of up to $350.

ReFresh Spot reduces these risks for homeless and other vulnerable people in the Skid Row community. Campos said the site has 23,000 intakes per month, with about 3,000 laundry washed and thousands of cell phone charges a month. It also helps connect people to HHCLA’s broader network of services.

Steps to Address This in Other Cities

Similar initiatives have taken root in other cities across the US in recent years. In 2017, local advocates in Washington, DC found that just 11 food establishments in the city’s downtown allowed pedestrians to use their bathrooms—and there were only two 24/7 bathrooms in the entire city. An activist group, led primarily by homeless and formerly homeless DC residents, pushed the City Council to pass sweeping public restroom legislation in December 2018.

DC will now study where and how to install clean “clean, safe, stand-alone public restrooms” operating 24/7. It will also encourage local businesses to open their bathroom doors through an incentive program. CityLab has noted that several cities in Europe and Australia offer cash bonuses to incentivize local businesses to make their bathrooms public.

In Seattle, Washington, the City Council has allocated $1.3 million in its 2020 budget to buy and staff five mobile bathroom facilities. Each facility would have hand washing and syringe disposal amenities, with a staffer to monitor safety. This came after a city auditor found in 2018 that only six bathrooms were open 24/7 in the city, and these too were often missing soap, had syringe litter, or were in disrepair. The city votes on this budget on November 25.

The real solution must include affordable and stable housing. In the meantime, 24/7 restrooms are a win-win.

San Francisco, California, city officials approved a six-month, $200,000 pilot program in the summer to operate three 24-hour public toilets. The city also hired full-time staff to maintain the facilities and monitor safety. “Access to public restrooms should be a fundamental right in San Francisco,” said Supervisor Matt Haney. “Public bathrooms, open and accessible, when people need them, are an essential part of urban life. People’s need to use a toilet does not end at 6 pm, and neither should bathroom access.”

San Francisco’s program works by expanding operational hours for existing Pit Stops—permanent or portable restrooms operated by the Department of Public Works. The city first installed the Pit Stops in 2014 in response to complaints from residents about waste in the streets, and now operates 25 of them.

Finally, in Portland, Oregon, Mayor Ted Wheeler and the City Council responded both to residents’ and public health concerns by approving a Hygiene Street Response program. The program will fund six portable bathrooms and showers in high-traffic areas, with on-site staff to monitor and maintain them.

The city will build the facilities, but then give them to local homelessness non-profits to operate. The sites will hire local homeless people as “public space managers” tasked with looking after the toilets and collecting data on their usage. The city is allocating over $870,000 for this program for 2020.

While expanding public toilets will benefit homeless people with nowhere else safe or sanitary to go, the real solution must include affordable and stable housing. In the meantime, 24/7 restrooms are a win-win both for homeless people and general public health. Cities have no excuse not to support an intervention that promotes human dignity, prevents the spread of disease and saves costs in the long run.

Photo of tents in the Skid Row neighborhood of Los Angeles by Russ Allison Loar via Wikimedia Commons.