Open Defecation in the United States: Perspectives from the Streets

Introduction

Open defecation (OD), most often problematized in the rural areas of developing countries, is increasingly difficult to ignore in urban settings, including those in the United States. ¹ Take a stroll through the streets of Miami, ² Atlanta, ³ San Francisco, ⁴ or other major U.S. cities ⁵ and you may stumble on discarded human feces where OD serves as an indicator of the epidemic of homelessness in many areas. When piles of feces litter our streets, concerns about human dignity and fears about the transmission of infectious diseases are valid.

Safely managed sanitation is essential for public health. Flush toilets, sewers, and septic tanks provide a physical barrier between people and their excreta. Uncontained feces in the environment poses a risk for infection through a variety of environmentally mediated pathways. In low- and middle-income countries (LMICs), OD is associated with morbidity from diarrheal disease, malnutrition, and increased child mortality. ⁶ Recent outbreaks of infectious disease associated with poor sanitation among people experiencing homelessness in high-income countries indicate that OD and overuse of limited facilities available to homeless people are risks to public health everywhere. ⁷ A study from Capone et al. in Atlanta found that 23% of freshly discarded stools tested positive for one or more enteric pathogens, suggesting that this issue warrants further investigation across the United States. ⁸

From 2017 to 2018, the United States witnessed a devastating outbreak of Hepatitis A Virus (HAV). Nearly 600 cases of HAV occurred in San Diego, more than 400 people were hospitalized, and 20 people died. ⁹ Spread through direct person-to-person contact, the outbreak quickly expanded to Arizona, Utah, and Kentucky; the transience of people experiencing homelessness and poor sanitary conditions contributed to the spread of new cases. ¹⁰ In total, 12 U.S. states experienced outbreaks of HAV between 2017 and 2018, resulting in more than 7000 cases, 2800 hospitalizations, and 60 deaths. ¹¹ According to the U.S. Centers for Disease Control and Prevention (CDC), most cases occurred among people experiencing homelessness who may have lacked adequate sanitation at shelters and in public spaces. ¹²

The human dignity of rough sleepers (people experiencing homelessness in unsheltered locations) is particularly at risk within the United States. Access to clean water and sanitation is one of many human rights, recognized by most high-income countries, that has not been fulfilled for people experiencing homelessness within the United States. ^{13 , 14} Although the WHO/UNICEF Joint Monitoring Program for Water Supply, Sanitation and Hygiene reports that 100% of the U.S. population has access to at least basic sanitation, ¹⁵ complete realization of this purported universal coverage requires consideration of people experiencing homelessness. Accountability for the protection of the right to water and sanitation falls on states who must “Maintain clear and effective mechanisms to respond to requests and concerns from affected populations.” ¹⁶ Public toilets, available 24 hours per day, are one such solution employed by many countries to address the lack of access to sanitation for the street-bound homeless. However, the high cost of purchasing and maintaining such facilities, combined with barriers to using them by rough sleepers suggests that public toilets may not be enough to end the practice of OD.

Permanent supportive housing (PSH) is a potentially cost-effective solution to the public health problem caused by OD and the ethical problems associated with the indignity of homelessness. The provision of PSH is in keeping with the human rights principle of interdependence, a recognition that all human rights are interconnected and that the fulfillment of environmental justice is dependent on many sectors. ¹⁷ In addition, cities can boast of clean streets and attractive downtown areas for tourists and businesses alike. Housing unsheltered people eliminates practical barriers to using public toilets and provides the privacy and dignity that all people are entitled to.

Discussion

A 2010 United Nations (UN) resolution reiterated the human right to physical and affordable access to sanitation, ¹⁸ underscoring existing international human right norms ¹⁹ and clarifying that sanitation must be safe, hygienic, provide privacy, and ensure dignity. The United States supported the creation of this resolution ²⁰ ; however, the United States abstained from voting and is not legally responsible for ensuring equal access to sanitation, since it is not a party to the International Covenant on Economic, Social and Cultural Rights. ²¹ Former and current UN Special Rapporteurs on the human right to safe drinking water and sanitation have repeatedly addressed the implications of the U.S. government's lack of responsibility for ensuring adequate sanitation. ²² Although urination and defecation are necessary biological functions, limited access to public sanitation facilities in U.S. cities, combined with statutes prohibiting public urination and defecation, leads to the discrimination and criminalization of people experiencing homelessness. Despite the lack of U.S. participation in international human rights mechanisms related to the right to water and sanitation, the high levels of access to sanitation among the general population offer promise for more vulnerable populations such as the homeless.

Addressing OD naturally falls under the purview of the U.S. Department of Health and Human Services, as the lead agency responsible for the health protection of Americans. However, no current national public policy exists; the development of such a policy is a natural and necessary first step. Without federal guidance, the responsibility of public sanitation falls to each city. Due to financial pressures, many cities across the country lack adequate public sanitation. The New York City subway system once maintained 1676 public toilets; today there are 129. ²³ A 2017 audit in the Skid Row area of Los Angeles found that 1777 people experiencing homelessness relied on just 9 public restrooms during nighttime hours, falling 80 toilets short of the UN sanitation standards. ²⁴

According to Partners for HOME, the Atlanta homeless continuum of care, there were 3076 people experiencing homeless counted on a single night in January 2018, with 24% sleeping unsheltered, ²⁵ a significant decrease from the peak of the financial crisis in 2010 when 7019 people were counted, with 31% sleeping rough. ²⁶ Partners for HOME also identified that the number of chronically homeless individuals had decreased by 3% in the previous year, whereas the percentage of chronically homeless people sleeping outdoors more than doubled, due, in part, to the closure of the 700-bed Peachtree-Pine homeless shelter. Despite the dramatic increase in rough sleepers, we are unaware of any new public toilets or sanitation facilities in Atlanta since the closure, which may have helped to meet the increased need. Strengthening the capacity of state and municipal governments to provide public toilets is another form of human accountability that contributes toward environmental justice. ²⁷

However, expanding the number of public toilets may not be as impactful on OD among rough sleepers as public health and human rights advocates might hope. Capone et al. noted that many OD sites were within a quarter mile of a shelter, soup kitchen, or public restroom. Though the distance to any toilet was not measured, private businesses often only allow paying customers to use their bathrooms. Lack of public resources, perception about public toilets, feeling unwelcome in soup kitchens and shelters, safety, as well as physical and mental illness—including addiction—are all factors contributing to OD among many rough sleepers.

During the past 9 years of practicing Street Medicine—the provision of health care to rough sleepers outdoors where they live—I (Dr. Frye) observed a wide range of reasons for why unsheltered people may not use public toilets, including physical illness, the inability to tolerate being around other people, paranoia, other symptoms of mental illness, and practical issues associated with sleeping outdoors. As a street psychiatrist, I have observed that people who predominantly sleep outside—instead of in shelters—tend to experience high levels of post-traumatic stress disorder (PTSD), severe social phobia, paranoia, schizophrenia, alcohol and other substance use disorders, cognitive disorders, and intense mistrust in systems intended to care for them. For these reasons, many unsheltered people prefer to sleep rough, given the option between a shelter and the outdoors, though this choice should not be construed as a choice to be homeless. People who prefer to sleep outdoors, out of fear and mistrust, are also more likely to avoid public places where restrooms are available and may be more likely to defecate outdoors. Similarly, people with cognitive impairment (caused by schizophrenia, traumatic brain injury, and dementia) have more difficulty with executive function, which is required to plan and organize a trip to the restroom.

In addition to the mental and emotional reasons for avoiding public restrooms, physical health problems among unsheltered people are likely to contribute to OD. One Street Medicine patient, for example, was physically unable to sit or walk and required help from friends to throw his soiled clothes in the woods every time he defecated for several years. People who live unsheltered in the United States die prematurely, with 3 times the odds of death compared with sheltered people experiencing homelessness and 10 times the odds of death compared with the general population in a 10-year period. ²⁸ Many also suffer from advanced stages and symptoms of physical health problems before they die, such as chronic liver disease, cancer, and heart disease. ²⁹ Acute and chronic physical health problems likely have a direct impact on the likelihood of practicing OD, as many can cause diarrhea and bowel urgency, or may limit mobility. The incidence of acute diarrheal diseases or chronic conditions causing diarrhea among U.S. rough sleepers is unknown and likely difficult to measure. Among the causes of diarrhea, frequent and heavy use of legal and illicit substances changes bowel motility; mild-to-moderate alcohol use can cause diarrhea, as does withdrawal from opioids. ³⁰ Musculoskeletal problems and leg pain are found in high prevalence among unsheltered people. ³¹ When faced with a quarter-mile or longer walk to the nearest restroom, these limitations force some rough sleepers to risk soiling their only set of clothes in search of an accessible toilet.

Aside from physical and mental health symptoms as causes for OD, stigma toward injection drug users and unsheltered people plays a role, given the use of public restrooms as injection sites. Custodians of public toilets and staff at locations serving people experiencing homelessness—such as shelters, soup kitchens, and churches—often deny restroom access to unsheltered people and anyone else who they suspect to be an injection drug user. People experiencing homelessness are likely not to return to places where they experience discrimination, whether they use injection drugs or not. Equally, not all people experiencing homelessness are welcome in all places that serve the homeless; rough-sleeping people encountered by Street Medicine teams report being “kicked out” of these places for unwelcome behavior. An under-recognized cause of disruptive behavior among unsheltered people is PTSD. They can be triggered by staff who are not trauma-informed, resulting in agitated or even aggressive behavior. Lack of access to toilets and inhospitality at some homeless service agencies further contribute to the problem of OD.

Negative experiences in and perceptions about public bathrooms likely also affect the willingness of unsheltered people to use available toilets. Although research has proven that the dry, aerobic environment of a public bathroom is not hospitable to microbes from the human gut and is often cleaner than other common surfaces, ³² many Americans perceive public toilets to be unsanitary. Rough sleepers uphold similar perceptions when they encounter unhygienic facilities such as public toilets that smell, are visibly dirty, or contain unflushed fecal contents from recent bathroom users. Overuse of limited sanitation facilities at shelters and in public spaces can lead to unhygienic conditions and may contribute to this perception. Several U.S. cities have decommissioned public toilets that are aimed at reducing OD because public funds were insufficient to maintain an acceptable frequency of cleaning and/or maintenance. ³³

OD for many rough sleepers can also be borne out of practical necessity. One Street Medicine physician points to the reason for OD: “There's a book you should read. It's called Everyone Poops,” ³⁴ implying that without adequate access to sanitation, rough sleepers will defecate wherever it is convenient. The need to carry all their belongings on their backs or keep them in public spaces further complicates the use of public toilets. Street Medicine teams observe hesitance among rough sleepers to be separated from their belongings for more than a few minutes. The frequency of theft limits the length of time that rough sleepers can leave their belongings unattended and cities also often use street clean-up crews and police to “move along” unsheltered people. Without permanent and safe storage for their belongings, rough sleepers risk losing their possessions when they are unable to defecate nearby.

In LMICs, studies have shown that women who openly defecate are at a greater risk of sexual harassment and violence when they travel to and from OD sites, especially at night. ³⁵ Women from LMICs also experience shame from OD, which is exacerbated when men see them urinating or defecating in public. To minimize the possibility of being seen by men, many women choose to relieve themselves at night to hide from the potential gaze of men, despite the risk of violence against them. ³⁶ In the United States, where public toilets are often not available 24 hours a day, women are put at increased risk for harassment, gender-based violence, and may experience shame when forced to resort to OD.

Without a doubt, public toilets have value. They provide an opportunity to reduce OD and serve nonhomeless urban residents and tourists. However, they insufficiently address the environmental health hazards of OD, which are disproportionately experienced by unsheltered people. Providing adequate and hygienic sanitation to rough sleepers requires equitable access to sanitation facilities when and where they are needed. ³⁷ Therefore, addressing inequitable sanitation access for people experiencing homelessness requires advocacy for adequate shelter. ³⁸

PSH is the necessary environmental justice response to OD in the United States. PSH programs help unsheltered people find a permanent home that meets their physical needs for housing and sanitation, and mental health services if necessary. Due to a paucity of research, there is insufficient evidence to claim that the PSH model saves health care costs or is cost-effective, ³⁹ although previous studies of PSH did not evaluate net societal benefits such as the public health gains by reducing OD. The benefits of PSH are not limited to cost-effectiveness, however, and stakeholders should promote the realization of human rights over any potential cost savings. The U.S. Department of Housing and Urban Development (HUD) has implemented PSH programs across the country, including Housing First. ⁴⁰ Increased funding and support for HUD initiatives such as Housing First will be necessary to realize the human rights of people experiencing homelessness and mitigate the public health risks associated with OD.

Conclusion

OD, borne out of necessity, robs unsheltered people of their self-worth and is inhumane. Within the United States, OD is an under-recognized public health and human rights problem that is solvable. Outbreaks of infectious disease from inadequate sanitation are a risk shared by all Americans. The United States being one of the world's richest countries, the U.S. government should not only clean up the aftermath of OD but also prevent its cause. Greater support for public toilets may provide some relief and should be instituted. However, PSH is the best path to realizing the rights of rough sleepers in the United States and, although its cost-effectiveness requires further consideration, its true value can be counted in improved health, longer lives, and the dignity of defecating in a hygienic and private facility.