The concept of public health is an interesting one. It can mean different things to different people because the health interests of the entire population make up its definition. The Centers for Disease Control and Prevention’s health protection work includes the CDC Foundation, an independent nonprofit created by Congress to mobilize philanthropic and private-sector resources to work with the government to save and improve lives by advancing public health. Improving sanitation services and hygiene must be an important part of this mission.
Back in November 2021, Bloomberg reporter Elizabeth Yuko penned a report under the provocative title “Where Did All the Public Bathrooms Go?” Something became evident during “the Great Toilet Paper Shortage of 2020,” she writes. “The pandemic revealed a different toilet-related problem that predated the novel coronavirus: a dire lack of public restrooms.”
Just the mention of public restrooms for many people represents not only an unwelcome subject (I apologize) but one that taps into social tensions that have been with us long before the current pandemic. But it is important to look at the consequences we face if this subject continues to be ignored.
Catarina de Albuquerque is chief executive officer of the United Nations Sanitation and Water for All global partnership. Nearly a decade ago, the United Nations assigned her the task of assessing water and sanitation services in the United States. “Despite being one of the wealthiest countries in the world, the U.S., I found, had woefully inadequate availability of public restrooms,” she writes in a recent Los Angeles Times opinion piece. “Only eight per 100,000 people on average, the same number as Botswana … Government leaders point to high costs for installing public toilets, but poor sanitation policies often end up costing much more,” she adds. She points to experiences in San Diego as but one case in point.
Reports newspaper Voice of San Diego, beginning in 2000, four grand jury reports warned that the city’s inadequate public restroom infrastructure could become a public health threat. This threat was realized in 2017 and 2018. “Hepatitis A swept through the city, sickening 582 people and killing 20,” reporter Bella Ross writes. In an updated report by the County of San Diego Communications Office, in August 2021, the county of San Diego declared an outbreak of shigella, a preventable disease linked to contact with human excrement. “The cases are primarily among individuals experiencing homelessness, with the majority at multiple locations in central San Diego,” says the report.
“Advocates and researchers argue the city’s public restroom shortage is not a problem that only affects unsheltered people,” reports Ross. “The city has a lot to lose by not addressing this issue, too, as it spends nearly $1 million a year cleaning human feces and other biohazards off the street,” she writes, citing a NBC7 investigative report. “The City Council (has) approved an additional $3.8 million — on top of about $3 million that was already allocated for the span of five years — for additional sidewalk cleaning in response to the shigella outbreak.”
“To be clear, this is not just a problem in America, but also in the UK, Belgium and many other countries across the globe,” notes de Albuquerque. “Imagine if this money were spent on public restrooms to prevent such problems … It should be an easy sell: Every dollar spent on urban sanitation brings a return of $2.50 to the economy through reduction in medical costs and increased productivity, according to the World Bank.”
In the not-too-distant past, increased public health measures went along for the ride with the post-World War II flight to suburbs and our increased reliance on cars, reports Yuko. Accompanying improvements in urban infrastructure included not only a proliferation of public toilets but “the rise of a different kind of public bathroom — the highway rest stop,” she notes. “Today, these options are also disappearing as state highway departments trim their budgets,” she notes.
“Fears of crime and vandalism in the 1960s and ’70s sped the mass extinction of many city-run facilities, which had acquired an unsavory reputation as sites of drug use and sexual encounters,” Yuko writes. “By the early 1980s, most of the restrooms located in New York City’s 472 subway stations were locked, and have largely remained inaccessible since … A final blow came in the form of the terrorist attacks of September 11, 2001, prompting the closure of public restrooms across the country for security purposes. Since then, the American city has largely been a no-go zone … As with so many other aspects of American life, Covid-19 exposed and exacerbated the American bathroom gap.”
Yet Harvey Molotch, an emeritus professor of social and cultural analysis and sociology at New York University, also sees the pandemic “as an opportunity to reconsider how public restrooms are built — particularly with regards to airflow.”
“Ventilation just makes life better,” says Molotch. “That goes for disease prevention, and of course, the noxious odor. If you increase the ventilation, it ticks off a whole lot of boxes where you have scored an improvement.”
According to Steven Soifer, president and co-founder of the American Restroom Association, some cities around the country “are leading the charge for public restrooms befitting the 21st century.”
“As in other chapters of public health history, this Covid-inspired rethinking of restroom function and design could inspire progress in areas outside of disease prevention,” she adds.
Not unlike the CDC Foundation’s work with philanthropic and private-sector resources in advancing public health, de Albuquerque writes that “while this basic service is a responsibility of government, there are plenty of models that encourage private-sector partnerships as well. Take San Francisco, which has joined forces with media company JCDecaux to fund the installation and maintenance of public toilets in exchange for allowing advertising kiosks on city sidewalks.”
“Ensuring the right to sanitation for all requires a conscious policy shift,” she says. “Done thoughtfully, this can promote human rights, guarantee affordability, and support public health systems and community development.”