Episode 65: Water and Housing Instability
“Something that I have in mind when I think about radical hospitality–to treat those who often feel invisible with an extraordinary level of respect, to open the opportunity to feel clean again
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“As far as interventions go, we need a cultural shift in people’s minds about our unhoused population. We do have a human right to water, sanitation, and hygiene in California and these people also deserve continuous access to safe drinking water, sanitation, and hygiene.
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A conversation with Drs. Alhelí Calderón Villareal (California State University San Marcos) and Georgia Kayser (University of California, San Diego) about the importance of water, sanitation, and hygiene (WASH) services for people experiencing housing instability. Released December 20, 2024.
guests on the show
Alhelí Calderón Villareal
Alhelí is a Medical Doctor who graduated from the Universidad Autónoma de Coahuila (UA de C), a Master on Public Health graduated from the Instituto Nacional de Salud Pública (INSP) in Mexico, and finished her PhD at the Joint Doctoral Program of Public Health - Global Health track at the University of California San Diego (UCSD) and the San Diego State University (SDSU). She is a co-director of Women in Global Health - Mexico Chapter, and Correspondent for Mexico in Pandemic Period Collective. Alhelí is also founder and director of the Social-Environmental Tijuana River Project. She has special training on global health, social and behavioral science and migration.
Dr. Calderón Villarreal has experience conducting research about Water, Sanitation and Hygiene (WASH) in several vulnerable populations during her master’s and doctoral studies. Dr. Calderón Villarreal founded and directed a transdisciplinary research group focused on the binational Tijuana River, studying water quality, and the water use, contact, and health outcomes among PWID who live inside this river. This project established her interest among the community of Person Who Inject Drugs (PWID). The results of this research study were published manuscript titled Deported, Homeless, and Into the Canal: Environmental Structural Violence in the Binational Tijuana River, published in the journal Social Science and Medicine in 2022, and were presented at the talk Structural Violence on the US-Mexico Border: Intersecting Forced Migration, Overdose, Water, and Human Rights Crises, presented with Dr. Joseph Friedman at the UCLA CTSI Distinguished Speaker Series 2022-2023.
Georgia Kayser
Georgia Kayser, PhD is an Assistant Professor of Global and Environmental Health in the Herbert Wertheim School of Public Health at University of California, San Diego (UCSD) and Deputy Director of the UC Global Health Institute Center for Planetary Health. Her environmental health research focuses on adolescent and children’s environmental health, water quality, environmental determinants of risk, and environmental health inequities and disparities. In her research she has explored the factors that limit access to safe and sustainable drinking water, sanitation, and hygiene (WaSH) services, globally; identified environmental determinants of risk, including pesticide and microbiological contaminants in drinking water; and examined environmental health disparities that result from gender, racial/ethnic, and geographic inequities. This research informs environmental health programs and policy. Her methodological expertise is in the use of cross-sectional studies to explore WaSH risk factors for disease across countries, formative research to identify interventions, experimental and quasi-experimental methods to test specific interventions, and geospatial analysis to understand patterns of exposure. She has conducted research in over 20 countries across the Americas, sub-Saharan Africa, and South Asia with funding from government, international organization, and private sector sources.
Dr. Kayser is currently working on a NIEHS funded K01 career award that explores pesticide exposures, mental health and endocrine disruption among children growing up near pesticide spray sites in Ecuador. She is also working on a NIDA funded study of WaSH access among people who inject drugs, many of whom are unhoused, and live on the US-Mexico border between Tijuana, and San Diego. Dr. Kayser enjoys mentoring students in her research and teaching environmental and global health courses at UCSD.
TRANSCRIPT
Sam Sandoval
Bienvenidos, Water Talk. Today, we're talking with two outstanding scientists Georgia Kaiser, Assistant Professor at UC San Diego, and Alhelí Calderón Villarreal, Assistant Professor at California State University, San Marcos. We're discussing access to drinking water, sanitation, and hygiene, particularly for homeless populations, people using drugs, and migrants along the border.
This is going to be a challenging conversation, but one I'm really excited about because, for many seasons, we've been thinking about who to interview and who can help us navigate the water issues surrounding these populations. I’m not well-versed in this topic, and I’m really looking forward to learning more. One thing I always keep in mind is the people who are around us but often overlooked. One of these communities is the homeless. I feel this episode will be humbling, as Georgia and Alhelí can share their experiences, and perhaps we can borrow their perspective to understand the issues they’ve studied, particularly along the border between San Diego and Tijuana.
Faith Kearns
I think it will be really interesting to talk to experts working closely on issues involving unhoused people, especially related to waterways. In California, this has been a significant issue, particularly as the housing crisis has grown. People end up sheltering near waterways or even in them, partly because of the ephemeral nature of some water sources, and partly because they can remain hidden along riverbanks. A big concern is what happens during the rainy season. There are always concerns from the community about unhoused populations, but focusing specifically along the US-Mexico border adds another layer to the broader issue. This is something I also see in rural Arizona, where many people live along the Verde River, my local waterway. I’m looking forward to learning how we can support these communities and consider the complex role water expertise can play in addressing these challenges.
Mallika Nocco
Faith, I really appreciate what you said about the water community considering these issues. It reminds me of a conversation I had about a year ago with some statewide extension specialists in California, where they were discussing the need to address water and housing together. The problem is escalating, and it’s clear that the water community’s expertise should be used to support people without secure housing. I also find myself thinking about the intersections between drinking water, sanitation, and hygiene. When I think about people who lack housing security, I often focus on food—where can I donate food, and so on. But water is just as essential, not only for consumption but also for sanitation and hygiene. I’m really interested to learn more about how these issues intersect.
Sam Sandoval
I agree with you, Mallika. As we broaden the conversation about access to drinking water, sanitation, and hygiene for unhoused communities, it’s clear this isn’t just a California issue—it’s a national one. This will be a great conversation for all of us to learn from and think about how we can contribute to helping these communities. So, without further ado, let’s talk with Georgia and Alhelí.
We’re excited to have the opportunity to speak with two scientists doing groundbreaking research. Georgia Kaiser is an Assistant Professor at UC San Diego in the Herbert Wertheim School of Public Health and Human Longevity Science. Alhelí Calderón Villarreal is an Assistant Professor at California State University, San Marcos, and the Director of the Collective Socio-Environmental Tijuana River Project. Both Georgia and Ali have extensive experience in the factors that limit access to drinking water, sanitation, and hygiene—what we refer to as WASH.
We’re really looking forward to learning from both of you today. We haven’t yet discussed the issue of homelessness and access to water, sanitation, and hygiene. I gave a brief introduction about you both—could you share your paths toward your fields of expertise and how you got here?
Georgia Kaiser
Sure! What brought me to studying water, sanitation, hygiene, and access—especially around drinking water quality—really started when I was in the Peace Corps in Ecuador, about 20 years ago. I lived in a rural village in the southernmost province of Ecuador. I had piped drinking water, but it wasn’t treated, and I didn’t have a latrine or bathroom, so I had to build one. I worked regularly at the village health center, talking to people about waterborne diseases. This really sparked my interest in WASH issues.
Later, I conducted research in Mexico, Guatemala, Honduras, and El Salvador, focusing on pollutants entering the Mesoamerican Barrier Reef system, which spans the coasts of Mexico, Belize, Honduras, and Guatemala. Many of the people I spoke with were concerned about water quality and health along the rivers flowing into the reef. These experiences, along with my time in the Peace Corps, shaped my interest in WASH access. I continued with this focus during my graduate studies at Tufts University, and later during my postdoc at the University of North Carolina at Chapel Hill, where I worked at the Water Institute. I also conducted research in Sub-Saharan Africa and Latin America. At every step, I was working on aspects of water, sanitation, and hygiene, looking at disparities and health inequities related to access—often focusing on rural versus urban resources, and gender disparities. That’s how I got into this field.
Sam Sandoval
What about you, Alhelí?
Alhelí Calderón Villarreal
Well, I’m Mexican and a physician. During medical school, I got involved with the International Federation of Medical Students’ Associations, where I learned about social determinants of health and global health. I became interested in the structural factors that affect community health, which led me to pursue a Master’s in Public Health at the National Institute of Public Health in Mexico, near Mexico City. For my thesis, I studied access to water, sanitation, and hygiene among Indigenous families in central Mexico. This was my first deep dive into studying water access and management at the household level. Another important factor was the growing problem of non-communicable diseases in both Mexico and the US. One contributing factor is the easy availability of soda and sweetened beverages, which made me think about how much easier it is for people to drink these instead of water, due to issues of quality, price, and accessibility.
I moved to Tijuana after my master’s, where I worked with a community living inside the Tijuana River—a community experiencing homelessness. Through this project, we discovered many of the needs these individuals face, particularly around housing and access to basic services. This experience led me to pursue my PhD at UCSD and CSU, where I met Georgia, who became one of my mentors. Now, I study access to water, sanitation, and hygiene among communities along the US-Mexico border, including those in Tijuana, San Diego, and homeless populations, as well as migrants and other marginalized groups.
Sam Sandoval
I've been thinking about this, and the unhoused population faces many challenges. Could you provide an overview of the challenges this population faces for us and our listeners?
Georgia Kaiser
I was just looking at some of the more recent statistics from the US Department of Housing and Urban Development. Many of us who live in major urban areas like San Diego, San Francisco, or Los Angeles may have noticed, but there is definitely an increase in the number of people experiencing homelessness in the United States. The latest statistics suggest that in January 2023, 653,000 people were experiencing homelessness in the US. This is the highest number reported since national reporting began in 2007. In California alone, about 181,000 people were homeless in a single night in January 2023. Even though there are more services, shelters, and permanent housing being expanded for this population, the numbers are still growing.
A lot of people I’ve worked with and mentored have started talking about this problem, especially when it comes to access to basic services. A lot of my work has focused on water, sanitation, and hygiene access among vulnerable populations. We started trying to figure out what kind of access these individuals had. It's difficult to find people and know where they’re living, but we began collaborating with different partners. One study was conducted with a student of mine in Los Angeles. It was a cross-sectional study of about 263 unhoused people living on Skid Row, looking at their access to water, sanitation, and hygiene (WASH) services.
We also collaborated with a colleague here at UC San Diego, Stephanie Strathy, who was already working on a cross-sectional study of people who inject drugs in San Diego and Tijuana, many of whom are unhoused. We began to look at and ask questions about water, sanitation, hygiene, and access to showers and the ability to wash clothing. There’s still so much work to be done, though. We’re really just scratching the surface, and there’s a lot more to learn. Alhelí can talk more about the study we did in San Diego and Tijuana since she was the lead author on some of those papers, and it was part of her dissertation research.
Sam Sandoval
And this is the perfect segue. Very recently, both of you have been working on a study about access to drinking water, sanitation, and hygiene for people who inject drugs and live along the US-Mexico border in Tijuana and San Diego. Can you describe that project and share your findings with our listeners?
Alhelí Calderón Villarreal
When we talk about people who use drugs, it’s very important to mention homelessness, because over 60% of them experience homelessness, at least on the US-Mexico border. This study included almost 600 people—586, to be exact. About 66% were from San Diego and 34% were from Tijuana, with more than 60% experiencing homelessness on both sides of the border. The characteristics of this population are quite similar, which is why we studied them as a binational metropolitan area. Although there are some differences, it’s surprising how similar the challenges are that they face on both sides of the border.
For example, only 56% of participants reported always having sufficient access to drinking water. As I mentioned earlier, half of them drink other beverages instead of water when they’re thirsty. This is a big concern because their health and wellness rely on proper hydration. In fact, 97% of them had a daily water intake below medical recommendations. Access to drinking water is slightly less secure in Tijuana than in San Diego, but both communities need increased access.
Access to handwashing facilities was reported by only 38% of participants. When we asked if they were always able to access these services, less than 3% said they could. A big challenge for this population is access to showers. Even though they may manage without drinking water or sanitation, taking a shower is one of the most difficult hygiene tasks for them to accomplish regularly.
This project includes three approaches. The first is a comprehensive study of access to water, sanitation, and hygiene, and the second is focused on people who menstruate. Women and others who menstruate also need water, sanitation, hygiene services, and access to menstrual products. Gender-based violence is a critical issue here. People need privacy, safe spaces to wash their clothes, and restrooms free of violence. We found that physical, verbal, and sexual violence are common when people use public facilities, like toilets or restrooms.
The third aspect of the study examines how insecurity in accessing these services is linked to incidents of abscesses. Our study found that, regardless of the country, individuals in this population had an increased likelihood of developing abscesses if they lacked access to showers, safe water to prepare drugs for injection, or practiced open defecation.
These are basic services we could help improve, and increasing access would greatly improve the health and well-being of this population. One of the biggest challenges is not only housing but also the violence—both direct violence and structural violence—and the environmental injustice that these communities face. People experiencing homelessness often live in environments that are riskier than those of other populations.
Sam Sandoval
Thank you, Georgia. Thank you, Alhelí. Georgia, do you want to add anything about the study done in Tijuana and San Diego?
Georgia Kayser
I really appreciate you highlighting that study. I just wanted to add to it by mentioning another cross-sectional study we did, which was led by a postdoc in the lab, Joanna Avilar Portillo. She worked with 263 unhoused people, not those who inject drugs, but just unhoused individuals living in Skid Row, Los Angeles. To add to what Alhelí mentioned, we found several additional challenges in this study. One major issue was access to sanitation at night. While public facilities might be available during the day, they were not open 24 hours. This left people without access to sanitation at night, forcing them to resort to open defecation or using buckets inside their tents. Not having basic bathroom access became a significant problem for the population we studied.
Additionally, some people were forced to use fire hydrants to access water, or they would rely on stores, but these aren’t open at night. So they had to carry water with them for the evening. Shower and laundry access were also big challenges, as unhoused individuals are often discriminated against if they appear unclean. This makes it difficult for them to find employment or even walk into stores without facing bias. Basic services like water and sanitation could really be improved for these populations in Los Angeles, San Diego, and Tijuana. There’s definitely a need for more people working to address these challenges. I just wanted to add these points to further highlight the issue.
Mallika Nocco
I have a follow-up question. Do you think the cities, like LA and San Diego, don't fully understand the scope of the problem and its specific aspects, or is it more of an issue where there’s awareness but not enough resources? From your perspective, why do you think there aren’t more 24-hour restrooms for these groups? Skid Row has been supporting these populations for a long time, so why are some of these issues still unresolved?
Georgia Kayser
That’s a great question, and I don’t have the full answer, but I can offer some insights. One big challenge is that there are city ordinances in places like Skid Row that call for encampment sweeps. These sweeps disrupt any access people might have to basic services, so when large encampments are cleared, people are forced to move, making it even harder for them to access water, sanitation, or hygiene services. While public facilities exist, they’re often only available during certain hours and might not be cleaned properly. Mobile wash services that provide mobile sanitation have been somewhat successful because they’re flexible and can move to where people are. However, they are funded by nonprofits, and maintaining this funding is challenging. Sometimes these services are available during crises, like the pandemic, but the financing often runs out.
There’s definitely room for cities to do more, and nonprofits could expand their efforts as well. Ali’s work highlights what can be done in harm reduction facilities, where people go for treatment. More focus on wash services in these settings could help. There’s also a need for a cultural shift in how we view the unhoused population. Policymakers need to recognize that access to basic water, sanitation, and hygiene services is a human right, and in California, it is legally recognized. A shift in perspective on how we treat people living on the streets could make a big difference.
Alhelí Calderón Villareal
San Diego and Los Angeles are cities with some of the largest unhoused populations. San Diego, for example, is the fourth largest in the U.S. The number of people is staggering—last year, the estimate for San Diego was around 8,000 people experiencing homelessness. Despite some efforts, there aren’t enough resources to meet the demand. Additionally, there are barriers that prevent people from utilizing shelters or other services. Many shelters don’t accept people who use drugs, which is a huge issue for people who need help but can’t access those services. In Tijuana, it’s the same—many shelters don’t allow people who have recently used drugs, which excludes a large part of the population.
Another barrier is family separation in shelters. People experiencing homelessness often choose to remain on the streets rather than be separated from their families. Pets are another issue—shelters typically don’t allow pets, so people choose to stay outside with their animals. There have been some positive changes, like one major shelter in San Diego that now allows families to stay together and allows pets, which could have a significant impact. In Tijuana, the population is smaller—around 1,000 people—but the resources there are even more limited. The approaches needed for these two cities are quite different.
Although access to water, sanitation, and hygiene (WASH) services is lower than national standards in both countries, it’s important to address the differences in need between the two cities.
Mallika Nocco
A big part of what both of you have spoken about, albeit indirectly, is the need to change our perception of people experiencing housing insecurity. One concept you’ve mentioned in your work related to this is "radical hospitality." Can you explain what that means?
Georgia Kayser
I’d be happy to. Some of the mobile water and sanitation services, like Lava May, use the concept of "radical hospitality" in their work. I’m actually reading from Lava May’s website right now. Unfortunately, they’ve had to close some of their mobile wash services due to a lack of funding, but their approach really resonates. They emphasize treating people who have often felt invisible with extraordinary respect. They see these individuals as their guests, offering them services like a hot shower and a warm towel, because they believe everyone deserves to feel valued. On their trucks, it says, "We consider you to be our guest, and it’s our honor to serve you." This concept of radical hospitality is crucial because it reflects the importance of treating people with dignity, something often overlooked when discussing unhoused populations. It’s not just about providing a service—it’s about offering respect and care.
Alhelí Calderón Villareal
Yes, exactly. Radical hospitality is about treating people who often feel invisible with the utmost respect and giving them the chance to feel clean again. Hygiene plays such an important role in this—it’s remarkable how lack of access to basic hygiene can lead to increased violence, discrimination, and decreased self-esteem. For many, being unable to practice basic hygiene prevents them from doing simple things in their daily life, and it compounds the challenges they face. Radical hospitality offers a way to restore dignity and help people regain some of their humanity.
Mallika Nocco
Yeah, that makes sense. It goes back to what you were saying about just trying to bring back humanity, right? So, without hygiene, you don’t feel human. That’s why I like the hospitality aspect—it’s like, everybody deserves hospitality. That’s also part of being human and trying to change minds. I like that framework for changing minds.
Sam Sandoval
We always like to end our podcast by asking How can we support your work, and how can our listeners help? Is there anything else you’d like us to know about your work?
Alhelí Calderón Villareal
Well, from my more activist side, I’d invite you to follow the Tijuana River Project on social media. You can find us as "Proyecto Socio Ambiental Río Tijuana." You can join us in the debate and learn more about the two NGOs, Casa and Proyecto Teresa del Casiona Mental. These two NGOs are working closely with the community and addressing the daily challenges this population faces in Tijuana. You can see what they are doing.
Sam Sandoval
Yeah, gracias Alhelí. Georgia?
Georgia Kayser
Well, I think we’ve covered some suggestions and ideas, but I’d say that a cultural shift in how people view unhoused populations is crucial. As Ali mentioned, they are people, and we have a human right to water, sanitation, and hygiene, especially in California. These individuals deserve continuous access to safe drinking water, sanitation, and hygiene. So, one thing people can do is look for nonprofits providing these services.
I agree with Alhelí—many of these services are like a temporary solution, like mobile services. Ultimately, wash services are tied to housing. If people don’t have housing, they won’t have access to wash services. Some nonprofits provide temporary services, but sustainability and long-term funding can be challenging for them. I think nonprofits need continuous support, but the challenge of long-term funding is something we should keep in mind.
Another thing people can do is just think of the unhoused as people. When you vote on issues related to homelessness or discuss it with your neighbors and friends, spreading a positive and humanizing view of the unhoused population can make a big difference. These are basic services that people need.