Skip to Content
Healthy and Affordable Housing

Lessons from Los Angeles: Sanitation as Health Justice for People Experiencing Homelessness

June 7, 2018


The United States is currently experiencing the worst multi-state outbreak of hepatitis A virus (HAV) in over 20 years. Because HAV often spreads through close contact and the oral-fecal route, proper sanitation and hygiene are important for preventing infection and promoting public health. People experiencing homelessness (PEH) often have severely limited access to restrooms, hand sinks, showers, or laundry facilities, and are forced to urinate and defecate in public spaces without the ability to wash up. Without access to proper sanitation and hygiene, the HAV outbreaks have primarily impacted PEH.

Los Angeles (LA), California stands out for some of its community and local government efforts to address these shortfalls. In 2017,  a group of nonprofit and government organizations, service providers, and residents in LA’s Skid Row neighborhood audited local public toilet access, finding severe shortages of adequate, accessible, and functional restrooms. For example, they found only nine public toilets for every 1,777 PEH during overnight hours—80 short of the United Nations sanitation standard for long-term refugee camps. The group also crafted recommendations based on audit findings and input from PEH on what changes would help most. Local policymakers responded by pursuing interventions such as the Skid Row Community ReFresh Spot, a pilot personal care center expanding access to public sanitation and hygiene services, with community input on design and implementation.

Beyond public service improvements, PEH can gain private access to sanitation and hygiene infrastructure through permanent supportive housing and other homelessness solutions. According to LA’s 2018 Point-in-Time Count released May 31, increased investments in such solutions contributed to decreased total, chronic, and veteran homelessness for the first time in four years.

A number of legal and policy tools enable public and private actors to respond to the multi-state HAV outbreak and promote sanitation and hygiene access for PEH. For example:

  • Emergency powers can quickly mobilize resources in response to disease outbreaks. In California, emergency declarations at the state and local level enabled accelerated procurement and provision of 24-hour public toilets, handwashing stations, vaccines, street cleanings and other responses to HAV.
  • Municipalities can develop written sanitation and hygiene strategies that assess existing public toilet, hand sink, shower, and laundry infrastructure, provide policy objectives, and set out an action plan. Several Australian cities take this approach. For example, the Kingston Public Toilet Strategy outlines a framework and 10-year work plan for improved service provisions, safety, inclusivity, cleanliness and investment. 
  • Local governments can build on healthy planning efforts by incorporating sanitation and hygiene infrastructure into general plans, zoning ordinances and Complete Streets polices.
  • Jurisdictions can adopt a Homeless Bill of Rights to safeguard existing and secure new legal rights to sanitation, hygiene and housing.  
  • Businesses can follow Starbucks’ recent example and amend corporate policies to open their toilets to the public, regardless of whether individuals make a purchase.

An upcoming Network for Public Health Law issue brief and June 28 webinar will examine the population health consequences of inadequate sanitation and hygiene access on PEH, highlighting legal, policy and community strategies that promote equitable access to these essential public health services.

The Network for Public Health Law can assist your efforts to advance health justice for PEH and other vulnerable populations through strategic legal and policy technical assistanceresources, and training on the use of law to safeguard and promote public health. As part of our work on these issues, we are dedicating a session at the 2018 Public Health Law Conference to share legal, policy, and community strategies to further health justice for PEH.

This post was developed by Walter Johnson, M.S.T.P., Legal Researcher and J.D. Candidate, and Madeline Morcelle, J.D., M.P.H., Staff Attorney, at the Network for Public Health Law – Western Region Office, Sandra Day O’Connor College of Law, Arizona State University. The Network for Public Health Law provides legal information and technical assistance on issues related to public health. The legal information in this post does not constitute legal advice or representation. For specific legal advice or representation, readers should consult an attorney in their state.

Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not necessarily represent the views of, and should not be attributed to, RWJF.

On a single night in 2017, an estimated 134,278 people experienced homelessness in California—fewer than 0.003% of the total state population. From November 24, 2016 through March 3, 2018, an alarming 367 of 704 (52.13%) diagnoses, 283 of 460 (61.52%) hospitalizations, and 15 of 21 (71.43%) deaths in the state’s HAV outbreaks affected individuals who reported experiencing homelessness, especially in unsheltered locations. Email from Sarah New, Epidemiologist, California Department of Public Health, to Madeline Morcelle, Staff Attorney, Network for Public Health Law — Western Region Office (April 17, 2018, 10:36 MT) (on file with author).