EDITOR'S NOTE: This story is part of The San Francisco Chronicle's SF Homeless Project.
The state of San Francisco’s sidewalks has generated outrage for decades. But every joke about poop and complaint about smells misses the point – that the city has a public health emergency that it could fix, but doesn’t. And it’s one that destroys people’s dignity on a daily basis.
“Bathrooms are the least common denominator,” says Margot Kushel, an internist at San Francisco General Hospital and a professor of medicine at UCSF’s Center for Vulnerable Populations, who conducts research on the health effects of homelessness on older adults. “The reason people need hygiene facilities is that they do not have housing. It’s a statement of how bad the problem is that we’re talking about these bandages. It’s a bellwether for how far we are from housing our community.”
There are physical consequences of not having access to a bathroom, ranging from skin breakdown to tooth decay to urinary tract infections. But the physiological effects are “almost secondary compared to the enormous effect on mental health, on a person’s ability to obtain social support and their ability to engage,” says Kushel. The city’s inaction on providing adequate facilities plays a major role in keeping people from exiting homelessness.
At a legislative level, going to the bathroom in public is considered a criminal activity, despite being a basic bodily function that every individual would prefer to do indoors. (Kushel brings up the children’s book, “Everyone Poops,” as an instructive document.) According to the Budget and Legislative Analyst’s Office, last year alone, San Francisco spent more than $20 million penalizing homeless people for violating “quality-of-life” laws, one of which is the law against urinating or defecating in public.
“By virtue of saying it’s an illegal activity, you’re discriminating against those forced to do it in public. Houseless people are eventually going to break the law,” says Paul Boden, the director of the Western Regional Advocacy Project and the former director of San Francisco’s Coalition on Homelessness.
And toilets are just one aspect of the story – the need for hygiene facilities includes showers and washing machines. The nonprofit Lava Mae has worked to fill the gap with mobile showers installed in decommissioned Muni buses, but they’re a relatively small operation and not designed to be a replacement for infrastructure. A scattering of places like the Mission Neighborhood Resource Center, which has a couple of showers and a washing machine, are open for limited hours.
Boden was homeless for six years when he was in his late teens and early twenties. He recalls that the city used to have a much more robust system of public hygiene facilities. “When I was on the street in the early 1980s, you could take showers down at Aquatic Park,” he says. “But when homelessness started becoming a problem, the response was to close the bathrooms.”
He says that when he was coming off the street, what took the longest time to recover were his teeth and his feet. “When we talk about hygiene centers, people think we’re just talking about toilets. It’s not just about toilets. The health conditions that could be alleviated by access to hygiene centers are astronomical.”
Feet take a beating when you can’t change into fresh socks, and not being able to wash leads to soft tissue infections, which then get progressively worse when they aren’t cleaned. Unsanitary conditions can also generally contribute to the spread of disease.
Former Assemblyman Tom Ammiano introduced a bill in 2012, AB 5, which as part of a “homeless bill of rights” would have required the State Department of Public Health to fund “hygiene centers” with showers and bathrooms, but it died in appropriations. Boden, whose organization co-authored the bill, says the idea was to attach the centers to existing neighborhood-based health centers.
Sam Dodge, the director of the Mayor’s Office of Housing Opportunity, Partnerships and Engagement (often referred to as the city’s homeless czar) started the Pit Stop program in 2014, which now has 14 locations with public toilets that are monitored by employees.
But, he says of progress that’s been made in the past few years, “All of these things are kind of half-steps.”
“Part of the infrastructure of San Francisco traditionally has been bathhouses,” he says. “During the AIDS crisis they were steadily eliminated. But it’s clear that there needs to be a kind of public bathhouse.”
The biggest problem, Kushel says, is people’s dignity – the damage inflicted by having to walk around in soiled clothing. “The main effect is of stigma and shame, which impacts a person’s ability to exit homelessness. It’s hard to search for work when you have soiled clothing, hard to present yourself to apply for housing.”
“I can’t tell you how often I go to examine someone and they don’t want me to examine them because they think they smell,” she says. “If you feel like you smell you might not attend church or go see your family. You’ll be embarrassed and ashamed. And people look down on you and isolate you more.”
There needs to be a paradigm shift, she thinks – we have to start thinking of housing as health care.
“Housing is health care. As soon as people lose their housing, their chronic disease management gets worse. Their acute needs and their need for institutional care become higher. There are very few diseases as potent as homelessness,” she says. “If you had one thing to predict whether someone would be re-admitted to the hospital or die prematurely, there are very few constructs as potent as housing. If our goal is promote health, this is one of the most important interventions we can do. Everything else is dwarfed.”
Dodge and Kushel agree that the housing issue is solvable – it’s a matter of connecting people with the services that are appropriate for their individual situations, and will require investment at the national level. “We have an insane housing system in our country where we have lotteries and years-long wait lists for necessary housing, and yet unlimited mortgage deductions in the tax code,” says Dodge. “The idea that this is unsolvable is a total canard. We should look at a universal right to housing like we do public education. It would cost about $60 billion a year to subsidize every low-income person’s rent. We absolutely have the money to do this as a nation.”
And Kushel says that locally we have to take responsibility as well. “It’s not unconnected that this region has so much wealth and so much poverty. You see the sort of anger leveled at the people experiencing economic displacement. We talk about not having money, but it’s a matter of political will,” she says. “And then we’re left having this discussion about toilets.”
Photo: Anna Challet / New America Media