Cities in the U.S. and elsewhere have made strides, but challenges remain.When a visiting friend asked if I wanted to go on a run in Philadelphia, I did a lot of planning. Not just our route, but where to go to the bathroom. It did not go well.I took the rapid-transit PATCO Speedline, which doesn’t have bathrooms on trains. The station I left from in Southern New Jersey didn’t have one either, nor did the one where I arrived in Philadelphia. When I arrived at my friend’s hotel, the lobby’s bathrooms were locked.Fortunately, I was able to follow a woman with a passcode into the bathroom. But that was a matter of luck. Relying on whims of fate was my only option because the United States — and much of the world — has a public bathroom problem.On average, the United States has only eight public toilets per 100,000 people, according to the Public Toilet Index, a 2021 report by the British company QS Bathrooms Supplies. That’s far behind Iceland, the country with the highest density of public bathrooms: 56 per 100,000 people. That number drops to four per 100,000 in New York City. Madison, Wis., led the way for U.S. cities, with 35 per 100,000.It wasn’t always this way. In the 18th century, before indoor plumbing, bathrooms were common and generally communal, said Debbie Miller, a museum curator at Independence National Historical Park. In Philadelphia, one such octagonal outdoor toilet was located in a public garden behind what’s now known as Independence Hall. “You could have shared the privy with George Washington,” she said.The acceptance of public and shared bathrooms shifted during the Victorian era, Ms. Miller said, when bodily functions became more taboo. The temperance movement to limit alcohol consumption led cities to build public restrooms in the late 1800s and early 1900s: The thinking went that men wouldn’t need to enter a bar to use the bathroom. In the 1930s, investment through the Works Progress Administration and Civil Works Administration added more than two million latrines in parks, on public lands and in rural areas, as well as “comfort stations” in cities, including in Central Park.A comfort station in Manhattan’s Central Park in 1965. Don Hogan Charles/The New York TimesBut as city budgets dried up in the 1970s, so did resources for maintenance. Movements arose to end the practice of paid toilets, which was seen as both sexist (urinals were often free to use but stalls were not) and classist. Cities responded by removing public toilets altogether.Bathrooms are “challenging spaces because they end up being, not infrequently, the places where people get needs met that they can’t meet anywhere else,” like sex work, drug use or sleeping, said Lezlie Lowe, the author of “No Place to Go: How Public Toilets Fail Our Private Needs.” “All of these are social concerns that have nothing to do with bathrooms, but because of the nature of those spaces, bathrooms end up being used for people to meet their needs, whether it’s dependency or desperation.”As public restrooms closed, establishments like coffee shops, museums, libraries and department stores — which are generally open only during certain hours — had to become gatekeepers of restroom access.“We’re faced with an issue where the demand for public restrooms far exceeds the supply,” said Steven Soifer, the president of the American Restroom Association, a group that advocates better public restrooms. “This gets into, who is responsible for providing public bathrooms?”There have been various approaches to answering that question. Some European cities have tried public-private partnerships, said Katherine Webber, an Australian social planning researcher who traveled the world in 2018 to study toilets with a grant from the Churchill Fellowship. She said the strongest programs involved local governments playing a role in determining best toilet locations. “A city or a place is going to be doing it better if they’re considering the different needs of both the residents and tourists.”In 2022, Berlin completed a public toilet expansion, which doubled the number of public restrooms from 256 to 418. The city looked at their existing toilets and identified where the gaps were — then partnered with Wall GmbH, a street furniture company that also builds structures like bus shelters and newsstands.The same year, London introduced the Community Toilet Scheme, where shops and restaurants could list their toilets as open to the public on the City of London’s website in exchange for a small fee. Business owners believed that window signs advertising restrooms would bring in customers.Each of these approaches has drawbacks, though: The Berlin toilets cost 50 cents per use, and the London Community Toilet Scheme is only useful during the open hours of the businesses opting in.A public urinal, also known as a pissoir, in France in 1875. adoc-photos, via Getty ImagesSome cities have adopted French “pissoirs” — essentially completely or semiprivate public urinals, which have been around since the early 19th century. In 2011, Victoria, B.C., installed urinals that doubled as street art, called Kros urinals, which have four spots per unit and can also be moved to special events or bars.But like the classic pissoir, they are typically only usable by people without disabilities and those who can easily use the bathroom while standing. “They’re solving a tiny problem for people who already have pretty good access,” Ms. Lowe said.Asian countries have taken a different approach, in part because of different cultural norms. Whereas Americans might approach public restrooms with trepidation because of past experiences with dirty or broken facilities, in China, Japan and Singapore, they expect their bathrooms to be clean, said Jack Sim, the founder of the World Toilet Organization. Between 2015 and 2017, more than 68,000 toilets were built in China in what became known as the “Toilet Revolution,” with a directive from the government to keep toilets clean.The public restrooms in Tokyo also serve as public art.Satoshi Nagare, via The Nippon FoundationA looming question is whether the program can be scaled to cover other parts of the city.Satoshi Nagare, via The Nippon FoundationSatoshi Nagare, via The Nippon FoundationThe exterior glass turns opaque when the bathroom is locked.Satoshi Nagare, via The Nippon FoundationTokyo turned its toilet program into public art. The Nippon Foundation sponsored the redesign of 17 toilets in the Shibuya ward, with striking designs, including a white hemisphere and glass walls that turn from clear to opaque when the bathroom door is locked. They will be cleaned and maintained through partnerships with the Nippon Foundation, the Shibuya City government and the Shibuya City Tourism Association. (A looming question is whether it can be scaled up to cover the large sprawling city.)American governments have been trying a patchwork of solutions. Some cities have had more success than others, though no one has conquered the problem. In 2008, New York City bought 20 self-cleaning toilets that cost 25 cents per use. But installing them stalled as the Department of Transportation works to find the right places for them, which have to meet an extensive list of requirements. Five are currently in operation, and the department is taking location suggestions for the remaining toilets — possibly a recipe for N.I.M.B.Y. (“not in my backyard”) complaints.San Francisco started the Pit Stop program in 2014, after hearing from children in the Tenderloin district that they were stepping around feces on their way to school, said Rachel Gordon, the director of policy and communications for San Francisco Public Works.The first public pay toilet in New York City, in Madison Square Park, in 2008. New York’s program has not scaled well. Ruth Fremson/The New York TimesThey started with three bathrooms, and today have 33, with hours varying by location. (The amount expanded to 60 locations when homeless shelters closed during the pandemic, Ms. Gordon said, but the temporary stalls have since been removed.) Each has running water, soap, needle disposal boxes and dog waste receptacles as well as one or two attendants working. According to a study conducted by the University of California, Berkeley, feces reports declined by 12.47 a week in the Tenderloin district during the six months after the first Pit Stops opened.The public restrooms in Portland, Ore., are available around the clock. The Portland Loo is a gender-neutral, wheelchair-accessible, single-stall bathroom that costs $100,000 per unit.The city created the concept in 2008 with a goal of building a simple structure that couldn’t be vandalized. Each bathroom is connected to the sewer system and has running water and electricity (provided by solar panels in some). The units are lit in blue, which makes it difficult to find veins and thus discourages drug use, said Evan Madden, the sales manager at Portland Loo.The toilets are ventilated to control smell and overheating; the vents also provide just enough privacy for the restroom’s purpose, but not enough for sleeping or sex work. It’s “intended to be uncomfortable for the occupant,” Mr. Madden said.In 2013, after Portland turned the sales and manufacturing operation over to Madden Fabrication, 180 units have been installed across North America.A gleaming public restroom in San Francisco. San Francisco Public WorksVancouver, Wash., installed three Portland Loos at a 7,000-acre waterfront park in 2018 — a response to typical problems: The city’s public bathrooms “have really taken a beating, and our police can’t monitor what activates are going on in them,” said Terry Snyder, the landscape architect for Vancouver’s Department of Parks, Recreation and Cultural Services.The Portland Loos have worked well enough that Mr. Snyder said the city would be installing three more this summer at the Esther Short Park, replacing a 22-year-old brick bathroom building.Philadelphia is also planning to install six Portland Loos in the next five years, with the first opening in Center City sometime this year.Mr. Soifer of the American Restroom Association believes that the issue in the U.S. should be addressed on a national level rather than having a patchwork of individual solutions. His group has had multiple meetings with the U.S. Department of Health and Human Services hoping it would step in to handle public restrooms — much like the Occupational Safety and Health Administration is responsible for toilets in the workplace — but to no avail.“Given that this really is a public health issue, someone has to take responsibility,” he said, “and no one is.”

At many of the Covid-19 recovery clinics that have sprung up around the country, patients’ goals include their athletic ambitions.At 17 years old, Nia Raquelle Smith enlisted in the Navy, and subsequently hurt her legs in a training accident, sustaining injuries that left her with nerve damage and on crutches for nine months. She was told that she’d never run again, and, determined to prove her doctors wrong, proceeded to run three marathons.Now, at 36, she is drawing on that experience as motivation to fight through her current setback: long-haul Covid symptoms so severe that until three months ago she could barely walk up a flight of stairs without needing an inhaler. Ms. Smith, who lives in Brooklyn, had planned to run in the 2020 New York City Marathon, which was eventually canceled; instead she has deferred that entry to the 2023 race.“This is going to be an even bigger challenge,” she said.As a veteran, she is being treated at the Margaret Cochran Corbin Campus of the VA New York Harbor Healthcare System and the New York University Veterans Clinic. There, as at many of the post-Covid-19 recovery clinics that have sprung up around the country, athletic ambitions are part of patients’ rehabilitation goals. Since the syndrome, sometimes known as post-Covid or long Covid, is still not well understood, doctors are throwing the kitchen sink at helping these patients get better — and get back to sport. They are adapting treatments used for other illnesses, and also — with permission — drawing data from athletes’ personal fitness trackers, like Apple Watches, Garmins and Fitbits, which endurance athletes use to tell them how fast and far they went. Some models also continuously track their heart rates to give clinicians a better look at how recovery is going, or not.The inability to be physically active can hamper recovery, too. “It can become a downward spiral of not feeling well to not being as active, to endurance dropping, so activity levels further drop,” said Dr. Benjamin Abramoff, director of the post-Covid Assessment and Recovery Clinic at Penn Medicine in Philadelphia, which opened in June 2020. Athletic patients have also lost a piece of their identity, as well as access to a valve for stress relief.“Running was how I managed my depression. It was the only time I was not thinking about everything that goes wrong in your life,” Ms. Smith said.Not being able to run has made coping with the lingering side effects of her illness, which include reduced lung capacity, cognitive delays, edema, neuropathy and post-traumatic stress disorder, much more difficult. In the past, “running was how I was able to escape,” she said.Patients with long Covid can present with a range of symptoms, including pain, breathing problems, heart abnormalities and fatigue. Nearly one-quarter of Covid patients have sought treatment for new health conditions one month or more post infection, according to a study from the nonprofit FAIR Health, which drew data from nearly 2 million patients’ private health insurance claims.To treat these patients, post-Covid clinics have formed around the country, 33 at last count, according to Becker’s Hospital Review.Penn’s clinic was the brain child of physical medicine and pulmonology specialists, with the idea of giving patients a medical home “where they can get an A-to-Z full evaluation, and we can track these patients when new research comes out,” said Dr. Abramoff, whose background is in treating spinal cord injuries. So far they’ve seen about 650 patients.Fatigue is a common complaint of their patients, he said. For athletes, it’s lost endurance. “There’s a good segment of patients who might feel OK while doing an activity but in the evening or days after, they feel lousy, can’t get out of bed and feel sick.”Until a few months ago, Ms. Smith needed an inhaler to get up the stairs. Now she carries it just in case she needs it.Desiree Rios for The New York Times“Running was how I managed my depression. It was the only time I was not thinking about everything that goes wrong in your life,” Ms. Smith said.Desiree Rios for The New York TimesPenn developed a physical therapy program, which varies according to the severity of each patient’s symptoms. “For some patients who were really seriously affected and can’t do any activities, how do we build back to the housework that you have to do on a daily basis? How do we pace that out across the course of the day so you don’t have to do everything at once?”For those with less severe symptoms, it’s a focus on gradually building back to activity, keeping the heart rate at 60 to 70 percent of their maximum at first. “If they tolerate it and are OK with it for a week or two weeks, we’ll build on that,” he said.Long-haul Covid patients tend to “have a honeymoon period, maybe two or three weeks after the acute illness,” said Dr. R. Kannan Mutharasan, a cardiologist at Northwestern Memorial Hospital in Chicago and co-program director of sports cardiology. “They’re finally feeling back to themselves and say ‘I’m going to go out for a run,’” he said. But afterward, they notice they’re not feeling the way they used to. A few weeks later, they may experience “things like lightheadedness, or a rapid heartbeat even when walking.”That’s what happened to one of his patients, Hannah Engle, 23, who was diagnosed with Covid-19 last July. She tried going for a run again in October, and her heart rate went up to 210 beats per minute. She is now on the “taking it slow” approach, but still hits setbacks if she overdoes it. In May, for example, she experienced chest pain and dizziness after what seemed like a simple workout with jumping jacks and stretching.Ms. Engle had always been an active person. As a child, she competed in diving, cheerleading and gymnastics, and even did gymnastics at the club level through college. After graduating, she continued to stay active through CrossFit, weight lifting and running 5Ks while working in Arlington, Va., to encourage people to go into the STEM fields — science, technology, engineering and math.Since long-haulers are still a new class of patient, Dr. Mutharasan is trying to take cues from treating patients with cardiac problems from conditions like postural orthostatic tachycardia syndrome (POTS), where problems with blood flow lead to abnormal heart rates, especially when sitting up or standing. That includes things like wearing compression socks to keep blood circulating to the head, and increasing salt intake to expand blood plasma volume. There’s no clinical data that this is effective with Covid long-haul patients, but anecdotally, Dr. Mutharasan said it’s helped about half his patients.He’s also looking at data: If patients wear any sort of fitness device, like an Apple Watch or a Garmin smartwatch, he asks to see their data from before and after their Covid-19 infection. Research published Wednesday in the journal JAMA Network Open underscores the role that fitness trackers can play in monitoring long Covid. Dr. Mutharasan particularly likes WHOOP, a fitness device that tracks heart-rate variability — the variation in time between heart beats.That number “will drop for a variety of reasons: overtraining, not enough sleep, too much alcohol, stress or where you are in your training cycle,” he said.The idea that higher heart rate variability generally means better cardiovascular health isn’t new; the new part is that patients can have that information themselves. “With the democratization of health care data and the ability for patients to have that data rather than just health care providers, anyone can get at this information with a smart watch,” Dr. Mutharasan said. It can also show that the body is taxed from something like long Covid, and how much.The goal is to make that number go up over time, which he said it typically does, even if it’s slowly.“Day to day you’re not going to notice the difference, and week to week you probably won’t notice, but month to month, you probably will,” he said.For Ms. Smith, the veteran, the slow pace of recovery has been challenging.At the time of her Covid infection in March 2020, she went to a hospital emergency room with double pneumonia. She was not considered sick enough to be admitted, but her long-haul symptoms have been severe. At a pulmonary fitness test in July 2020, her lungs showed the same capacity as someone with emphysema, despite no physical signs of lung damage on an X-ray.Making it up the stairs without needing to use an inhaler is a victory.Desiree Rios for The New York TimesShe is currently on four different medications, including Aricept (an Alzheimer’s drug), because of cognitive problems. On New Year’s Day, she and two friends from the NYC Bridge Runners, her running group, walked across the Brooklyn Bridge. What was formerly a small part of her regular running route took her nearly two hours to complete.But, she said, she is improving. She got a dog, a Havanese named Chuleta, early this year, which has forced her to go outside, no matter how bad her fatigue. Her medical team, orchestrated by a nurse practitioner, includes specialists in cardiology, pulmonology, rheumatology, speech pathology, physical therapy, neurological psychiatry, psychology and post-traumatic stress disorder.After a three-month leave of absence, she has returned to her job as a fund-raising manager for a nonprofit, and she started a new, gradual exercise program mid-June, beginning with yoga and stretching. Making it up the stairs without needing an inhaler is a victory, as well as a painful reminder of how far she has to go.Ms. Smith said she’s already been through so much, mentally and physically, because of her injury and then Covid, that she’s determined to return to running, and to run the New York City Marathon. “I can’t let this be taken away from me,” she said.