Health advocates say Portland needs more public toilets

The lack of public restrooms remains an issue across the country. In Portland, there are about 17 public restrooms per 100,000 citizens, according to some estimates.

When the city placed more than 100 red portable toilets around town in 2020, some residents vehemently opposed their arrival. In 2023, only about 16 of the toilets remained, according to KGW.

Public restrooms offer a low-barrier place for people to use the bathroom and wash their hands. The Centers for Disease Control and Prevention recommends carefully washing your hands with soap and water after going to the bathroom and changing diapers to prevent shigella infections. The bacteria causes inflammatory diarrhea.

In Multnomah County, shigella infections have been on the rise, according to The Oregonian/OregonLive. In 2023, a similar cluster of cases occurred as well.

Merilee Karr is the president of Phlush, an organization that advocates for better public sanitation. She joins us with more on why Portland and other cities would benefit from more public toilets.

Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.

Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. When you’ve got to go, you’ve got to go. But what if there is no place for you to go? My next guest says that public toilets revitalize downtown areas, are fundamental to human dignity and contribute to public health, as evidenced, for example, by the current increase in dysentery cases from the Shigella bacteria.

Merilee Karr is the president of Phlush – that is with a “Ph.” It is an organization that advocates for better public sanitation. She joins us now. It’s great to have you on the show.

Merilee Karr: Great to be here, Dave.

Miller: How did you get interested in the topic of public bathrooms?

Karr: Well, I’m a family doctor, now retired. And my philosophy [of] healing is you give people the tools they need to save their own lives. That’s much more effective than throwing drugs at them or technology. I got into public bathrooms because I’m a neighborhood emergency team member and leader. And I realized that in disasters, dysentery is what kills most people most of the time. I teach a class for emergency preparedness called You Survived the Earthquake but Die of Dysentery.

Miller: And dysentery, I’ve seen it described as inflammatory diarrhea or diarrhea that could come from an infectious disease.

Karr: Well, it’s a very practical condition. Dysentery, or any diarrhea, happens when there’s something in your gut that your gut thinks should not be in there. And diarrhea is the gut trying to help the only way it can. And most cases of dysentery/diarrhea get better by themselves as long as you keep up with the hydration, replace the fluids. But some germs that cause dysentery are more invasive and aggressive. You need antibiotics to treat them.

Miller: One of your organization’s lines is that public toilets serve people who are restroom-challenged. So who falls into the category of restroom-challenged?

Karr: People who, in practical terms, won’t go out again if they can’t find a bathroom when they need to. People with kids, pregnant people, people with ulcerative colitis, older folks … especially older women, I have to say, as one. If they know they might not be able to find one, they just don’t go out, their lives shrink and our communities shrink.

Miller: You’ve just described the majority of the human population. And you didn’t even mention people who didn’t realize that they’ve, in that moment, fit that category, but all of a sudden there’s an urgent need. And pretty quickly you get to everybody, who may need an emergency bathroom.

Karr: Yes, we are all restroom-challenged, at least sometimes.

Miller: What has been happening with bathrooms in coffee shops, stores, other private but publicly open commercial venues?

Karr: Before the pandemic, there were a lot of restrooms on private property in restaurants and retail establishments that the proprietors allowed anyone to use. But since the pandemic of mistrust, those have been closed off, often even closed to paying customers. So those restrooms are taken off the table. And restrooms can be denied to you depending on how you look. I mean the question comes up, how many restrooms do we have per capita?

Miller: Yes, that’s on my list, right now. But your tone makes me think you’re not gonna answer that question.

Karr: Well, I’m going to give you a question instead of an answer. The number of restrooms depends on your skin color, how well dressed you are and how traumatized the proprietor has been by the last person that they had to clean up after.

Miller: You’ve talked to people for whom that word “traumatized” is accurate?

Karr: Yeah.

Miller: What have you heard?

Karr: As a family doctor, I recognize trauma when I see it. It’s a real issue that determines the course of one’s health life. People who have had to clean up from poop on the walls or just a big mess. And the mess is more traumatizing because in a country without a safety net, we’re all in danger of becoming homeless, mentally ill or addicted. So there’s a visceral fear of the people we might turn into. I’ve talked to restaurant managers and you can hear them shiver. They don’t wanna go there again. Plus, with the fentanyl epidemic, opioids, sometimes there’s a body in a restroom. That’s very traumatizing.

Miller: Does everything you’re talking about there, I can imagine it can’t help but make it more challenging for you to say, “the answer is more bathrooms.” If you’re saying you’re talking to people who say, “I’ve had to clean poop off the wall,” or go in and find somebody who has OD’d or who has died in my bathroom, and you’re saying, “yes, we need more bathrooms,” what do you hear?

Karr: We need more bathrooms with people paid to clean them up, so that they remain usable and welcoming to people. Even if bathrooms are a nexus of controversy, I think if we paint on them “this machine prevents dysentery,” that would focus attention on what’s really going on.

Miller: Would you write that? Or would you rather say something like, “the more of these there are, the less likely you are to have diarrhea.” It’s sort of a half-serious question about public messaging and if “dysentery” is literally the right word that you think the public should be given right now.

Karr: I think dysentery really is the right word – hat tip to the Oregon Trail game. It’s an impolite subject, an uncomfortable subject. And the more humor we can sprinkle over the situation, the more people will actually engage and do something about it.

Miller: So as we heard just now, it’s hard to give an exact per capita number of public toilets, public bathrooms in Portland right now. What about another way to attack that? Do you have a sense for the number that is enough, of how many there should be?

Karr: Nope. Not gonna give you that number. No one can give you that number. Because it’s not just a number, it’s how far apart they are. It’s how distributed the population of people who need them is. Phlush is working on mapping the ones we do have in April, in fact, next month. We’re working with The Bathroom Company out of San Francisco to convene volunteers for a treasure hunt to identify restrooms, what hours they’re open, how welcoming they are, take photos. So check the Phlush website for when we’re pulling people together for that.

Miller: And then this would be an app that people could use? What would you do with the data?

Karr: We would open the app to everyone who wants to go out and be able to find a bathroom when they need one.

Miller: I mentioned at the beginning that your organization doesn’t just talk about public health and human dignity, but also about economic revitalization. What’s the argument for that?

Karr: Businesses need foot traffic. And if you don’t have public restrooms, you don’t have foot traffic.

Miller: And if the businesses aren’t going to offer their own bathrooms, you’re saying that somebody else needs to step up and do that so that people will go to those businesses.

Karr: Yes, perhaps with something like tax increment financing, so that the businesses can support the restrooms that will help their business.

Miller: I want to turn to design. First of all, what do you think about the Portland Loo, which is, I don’t know, 17 years old or something. The design has been copied or licensed in places around the West Coast and in other parts of Canada as well. What do you think of it?

Karr: I think the Portland Loo was a great design for its time. Twenty years ago, that’s how Phlush was born, from neighbors in Old Town Chinatown who were facing the same questions about restrooms that we are now: why aren’t there enough, what should they look like, why should they be one place or another? And the founders of Phlush accepted that they didn’t know the answers and convened stakeholders, designers, Portland State wrote a report and the Pacific Northwest College of Art, workshopped designs.

The Portland Loo wasn’t a new idea, because it looks good. It’s also practical. It is vandalism resistant, but it turns out after 20 years of experience, it’s not vandalism-proof.

Miller: I’m not sure that anything is vandalism-proof.

Karr: Yeah, surprise. It addressed the problem of people passing out in the restroom with the band of semi opaque grill work in the bottom 12 inches, so someone could be rescued in time.

It’s very expensive, that’s a lot of steel and it has to be placed on the utility lines, or the utility lines have to be extended under the sidewalk to where you want to put the Portland Loo.

Miller: So what is the public toilet of the future? How would the design be different?

Karr: Well, I recognize I don’t know the answer to that question and I don’t think anyone else does either. Which is why I think Phlush should repeat the process that brought us to life, and bring together people to study the matter, to ask what would they get out of a restroom, and get a bunch of people together in a room and build a new Portland Loo for post-pandemic Portland, which I think the rest of the world will appreciate the design of.

Miller: But as you said before, this idea, any increase in new public toilets, it seems like it’s only going to work if they are maintained, if somebody is regularly cleaning them. Meaning, ongoing public money in support of what you’re saying is a public good.

Karr: Yes, and that is true of any public good. Some cities have buyers' remorse over buying a Portland Loo or two because they didn’t bother to allocate maintenance funds. What did they think was gonna happen?

There is a type of design I’m interested in which is semi-portable. They’re not plugged into utilities, they have tanks of clean water and used water, which means someone has to show up to empty the dirty water and refill the clean water. So there is a maintenance requirement built in. Someone will show up and look at it. I think that might be an aspect of restroom design for the future.

Miller: Merilee Karr, thanks so much.

Karr: Thank you.

Miller: Merilee Karr is the president of Phlush, an organization that advocates for better public sanitation.

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