Increasing Sanitation Access: The community feedback period for this idea began on 12/8/2018 and ended on 3/9/2019. *STATUS UPDATE*

What is the problem that needs to be addressed? Please describe how it is related to mental health.
Sanitation. People experiencing mental illness have decreased access to sanitation services that may include: trash pickup, hand-washing, and toileting/rest-rooming. These are major vectors for spreading disease via fecal-oral routes. As people who experience mental illness also experience downward drift into homelessness – access to sanitation is severely restricted and inconvenient.


Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
Orange County previously attempted addressing fecal-oral disease transmission by outlawing food ingestion. While a valid method to halting the fecal-oral disease vector, it has the nasty side effect of starving homeless/mentally ill people to death. The outcome measure implied was not tied to life expectancy, but instead cases of morbidity/mortality associated with Hepatitis A. There are many other fecal-oral vector diseases that include: Cholera C. diff Shigella Salmonella E. Coli Campylobacter Hepatitis A Hepatitis E Enteroviruses – associated with the Acute Flaccid Myelitis outbreaks in recent time Noroviruses Poliovirus – associated with paralysis similar to Acute Flaccid Myelitis Rotavirus Amoebas Giardia Cryptosporidium Toxoplasmosa – associated with TORCHES birth defects Tape Worms Ascariasas Addressing the fecal-oral vector with the traditional intervention of hand washing is more cost effective than administering vaccinations for each of the above diseases (many don’t have a vaccination).


What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?
Right now, the fecal-oral disease vector is not controlled with numerous reports of Hepatitis A, E-Coli, Acute Flaccid myelitis (polio like disease in children), and others. A valid hypothesis is that hand-washing is not intact in the food supply chain as current events report no point-source of disease outbreaks.


What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
While hand-washing is not new, access to hand-washing is severely restricted in most of Orange County. Business and public sinks tend to be behind locked or security coded doors. Locations that use a key lock are especially disgusting as that key is itself a vector for fecal-oral disease.


What is the project idea? Please describe how this project will operate.
Adding to building code or other incentives for real estate development to add publicly accessible sinks, soap, water and hand drying apparatus. Examples of businesses that have successfully implemented this policy are the Pacific City real estate development in Huntington Beach – sinks are open to everyone without any locks/security devices. Tokyo Central in Yorba Linda also has open access sinks/soap/hand drying. These locations are designed to reduce the fecal oral disease vector. Halt use of keys as a security measure to bathrooms as they are itself a vector for fecal-oral disease.


Additional Information:
The Centers for Disease Control ( cite handwashing as “one of the best ways to protect yourself and your family from getting sick.”


December 21, 2018


Innovations Team

Thank you for your submission. The innovation team needs additional information to explore this proposed idea. Please elaborate on your responses as best as possible so that we may work through our review process.

•What would the learning objectives be for this project?
•How would the success of this project be measured?
•How could both the learning objectives and success of this project be more strongly related to mental health?

Historically, many entities in the United States value understanding health disparities and inequities. Understanding what causes disparities and inequities can lead to interventions that reduce morbidity and mortality that disproportionately impact certain demographics. Previous United States National Institutes of Health (NIH) leaders have identified a disparity/inequity in life expectancy for people experiencing mental illness (40-60 years of life for people experiencing mental illness vs. 78.6 years of life for an adult in the United States). A valid hypothesis is that the outbreaks of Hepatitis A and other fecal-oral diseases in the homeless/mentally ill community contributed to the disparity/inequity in life expectancy measures for 2018.

Of the listed fecal-oral diseases, many are possibly associated with mental illness. Infectious disease insult to the central nervous system is associated with mental illness. Meningitis is many times mistakenly diagnosed as mania – so an infectious disease can cause mental illness like symptoms/signs. Some evidence suggests that infectious diseases could be a cause of mental illness ( – scroll down to Biomarkers of Immune Inflammation and Oxidative Stress) while PubMed lists 601 results for the search of “Communicable Diseases”[Mesh]) AND “Mental Disorders”[Mesh] . Toxoplasmosis – one of the TORCHES fecal-oral infectious agents – is thought to be associated with Schizophrenia so much that the CDC has a web page devoted to the topic ( while PubMed lists 109 results for the search of “Toxoplasmosis”[Mesh]) AND “Schizophrenia”[Mesh]. Many of the antipsychotics used to treat schizophrenia also have anti-toxoplasmosis activity ( ). Research has also explored treating Toxoplasmosis in people diagnosed with Schizophrenia to mixed results ( and Finally, the mental health sequelae from a devastating infectious disease, such as acute flaccid myelitis, polio, or a baby born/stillborn with a TORCHES birth defect, is significant and likely associated with anxiety or mood disorders such as depression.

As noted in the original submission, the United States Centers for Disease Control previously cited hand washing as “one of the best ways to protect yourself and your family from getting sick.” Since the submission, the CDC has updated its website ( to cite hand washing as “One of the most important steps we can take to avoid getting sick and spreading germs to others.” The CDC lists partners ( involved in implementing hand washing habits in the general population. Children are and have been trained on handwashing for many decades with songs like “Tops and Bottoms, Tops and Bottoms, Inbetween, Inbetween, Scrub them all together, Scrub them all together, Now they’re clean, Squeaky Clean.” When someone is trained from a young age on an essential daily habit, such as handwashing, and then has it taken away there is a period of confusion which includes feeling worthless, loss of dignity, insecurity, feeling like an outcast, etc. Such feelings deteriorate a person’s sense of being successful in a mental health recovery and deteriorates coping skills that include self-care activities such as handwashing.

The above description shows a strong linkage between infectious diseases/handwashing and mental health. In Summary:
1) A health inequity/disparity exists in life expectancy for people experiencing mental illness and an inability to access handwashing can be shown to contribute to this inequity/disparity.
2) Infectious diseases (ID) that impact the Central Nervous System / Brain can illicit symptoms/signs that appear like a mental illness, but are not a mental illness. The CNS insult for some of these ID may be reversable while others may not be reversible.
3) Infectious diseases are associated with mental illnesses as a possible cause or exacerbating sequelae.
4) Infectious diseases can cause devastating or catastrophic medical illnesses that are often associated with new onset mental illness – specifically mood disorders such as depression or anxiety disorders.
5) Taking away or restricting access to resources involved in essential self-care, such as handwashing, has a negative impact on self-esteem, self-worth, feeling secure, dignity, etc.

At least five distinct physiological/pathological/psychological mechanisms link handwashing to mental illness. The County of Orange can hire outside contractors to come up with a more extensive list of the linkages between handwashing and mental illness. It is assumed that this is adequate to show how the project submission is linked to mental health/mental illness.

Moving to learning objectives and measuring success focuses on attitudes and historical design of real estate developments. Real estate developers, owners and businesses are observed in present time to place toilets, urinals, sinks, soaps, and hand drying equipment together into a room with reduced access. Supermarkets have entire produce sections where people walk up and touch raw food without easy access to handwashing. The two real estate developments listed in the original submission were noted because the legacy of bundling sinks with toilets was abandoned. Instead, sinks are located in a public area/room adjacent to the restrooms, prominently located close to eating areas. The curious public health administrator at the County of Orange would ask “Why?”

What is it that keeps a significant majority of real estate assets designed in ways counter to the goals of the CDC, United States Agency for International Development (USAID), The Center for Global Safe Wash, Fight BAC! The Partnership for Food Safety Education, The Global Hygiene Council, the Global Public-Private Partnership for Handwashing and Healthy Schools, Healthy People – It’s a Snap. The design of real estate assets is even counter to the hand washing stickers the Orange County Health Department posts in most restaurant bathrooms and the Orange County Health Department website on handwashing (

An informed public health scientist would hypothesize a few possible lessons from this project:
1) Orange County stakeholders do what has been done previously without thinking. A lack of leadership exists to implement hand washing to protect the health of the population, including those experiencing mental illness/homelessness.
2) Orange County stakeholders have stigma and don’t want poor/homeless/mentally ill people in their community nor to live a long life. This is valuable information so that people who are poor/homeless/mentally ill can relocate out of unsafe communities that don’t want to protect life/property of people who are poor/homeless/mentally ill. Such information would likely foster litigation with increased damages. Someone will sue or add on to Orange County v. Orange County, it’s just a matter of time.

Orange County can hire outside contractors to come up with other possible lessons or successes of this project. There are probably many more, but these should be sufficient to show lessons do exist for this project.

Moving on to success. Success would be measured by easy access to hand washing without the need to travel far distances, spend excessive time nor debate/negotiate excessively to achieve this essential self-care behavior.

This project meets the learning goals of prevention, early intervention, involving a different population with a change, and a community driven practice outside of a psych ward. This project involves increasing services to under-served populations, increasing the quality of services, promotes interagency/ public-private collaboration, and increasing access to services.

Some additional information is required to understand why this is an important issue for someone experiencing mental illness.

From my own experience, I am a Food Stamps/SNAP recipient without access to kitchen facilities. Therefore, food purchases are done “just in time” from choices that don’t require any preparation and mostly at supermarkets. SNAP eligible food is limited to cold food only. Many of the cold food options require the use of hands – sandwiches, fruits, vegetables, cheese/crackers, etc. Supermarkets are some of the biggest offenders for finding hand-washing facilities and the facilities tend to be one sink per gender-supermarket. The sink is bundled with the toilet and therefore hand-washing access is denied when someone is using the restroom. Forget trying to wash fruits/vegetables in the supermarket bathroom. Last I checked, both real estate examples in the original submission of open access sinks do not accept SNAP as a valid payment option.

Avoiding foods that require hands – a strategy that some might recommend – involves cutting breads, fruits, vegetables, etc from the diet. This can be considered another cause of life expectancy disparity/inequity for a person living with mental illness. MyPlate recommends about 2 cups of fruit and 2 cups of vegetables per day.

Alternatively, when cash is available, eating at many inexpensive venues requires finding restroom facilities at adjacent businesses which may deny service based upon “restrooms for customers only” policies.

Innovations Team

Thank you for your idea submission. Upon review and discussion, it was determined that the idea is tied more strongly to public health rather than mental health and it is unclear what new learning this project could contribute to the field of mental health. The Innovation team is unable to continue exploring this idea under the MHSA Innovation component as proposed.

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