People of a certain age have long associated Oregon with dysentery, an old fashioned name for terrible diarrhea. That's because of the 1980s video game, Oregon Trail, in which millions of unsuspecting avatars died of dysentery and were buried under pixelated gravestones.
The bacterial disease, which can also cause fevers, vomiting and cramps, is rarely deadly anymore, thanks to modern medicine. But it is highly contagious and can make people sick for weeks.
It's also, for the most part, no longer a big issue in places with plumbing. Americans coming back from trips to countries with less sophisticated hygiene systems are among the primary groups at risk of ingesting one of the four strains of shigella bacteria that cause the debilitating symptoms.
But cases in Multnomah County among people who have not left the country nearly doubled last year, to 158 in 2024, according to the county health department. And the number appears to be rising: There were 40 confirmed cases just in January.
Health care providers who spoke to The Oregonian/OregonLive said they suspect the actual number of infections is higher because many people who get sick don't see a doctor. And they agreed that the county's growing unsheltered homelessness crisis has contributed to the rise in infections.
"Any situation where (you are) unable to wash your hands regularly will put you at risk for shigella and I think unsheltered homelessness certainly contributes to people just really not having places to do that," said Dr. Amanda Risser, a senior medical director for Central City Concern, a Portland-based health care and housing services provider.
Risser and Dr. John Townes, medical director for infection prevention and control at Oregon Health & Science University, said increased access to bathrooms and handwashing stations would be one clear fix.
"If you want to stop an outbreak of shigella, you give people toilets and soap and water," Townes said. "And you train them in how to wash their hands."
Close to 6,000 people are living outside in Multnomah County, according to the most recent county estimates obtained by The Oregonian/OregonLive. But there are only about 116 publicly maintained restrooms in Portland, according to a count by The Oregonian/OregonLive. That includes park bathrooms that are locked in winter and library bathrooms that are closed at night.
While housing and a private bathroom for everyone would be ideal, Risser said having a receptacle for infected stool alongside a sink stocked with hand soap in a public restroom is far better than the alternative: Defecating on the sidewalk. In that situation, the sick person has no place to wash their hands, which makes it easy to spread germs to others, and the infected stool is left on the street, allowing the hardy bacteria to hitch a ride on shoe soles. Unfortunately, she said, the sidewalk-as-toilet situation is a phenomenon she's seen a lot recently.
"Pretty much every day I go to work, I see human poop outside and that's new," Risser said. She said there was no medical reason connected to drug use that would explain the increase. Instead, she thinks it's an infrastructure issue. "I think people poop outside when they don't have anywhere else to poop."
Adam Solano, the dispatch manager for Ground Score, the organization that cleans many of Portland's streets of litter, said the problem of human waste outside is constant. He said he gets calls from his clean up crews two to six times a day to report it. Then he has to call the city's biohazard removal team.
Living outside isn't the only way to get sick. One recent cluster happened at a wedding where one of the food preparers was ill and hadn't washed their hands, according to Risser.
J. W. Mosher is pretty sure he picked up a dose of the bacteria while cleaning the toilets at the Clark Center, a residential program in Southeast Portland for men involved in the Multnomah County community justice system.
"It's no fun," Mosher told The Oregonian/OregonLive. "I just had uncontrollable diarrhea for two weeks before I went to the hospital."
Mosher, who was still sick a week after his hospital visit, would only have needed to ingest a microscopic amount of the bacteria to become ill. The ease with which shigella spreads is one of the characteristics that puts people living in group settings or without access to regular handwashing at higher risk.
Mosher said that what he saw left on the toilets he cleaned indicated he was hardly the only one at the Clark Center suffering from the condition. Thousands of homeless people - 11,912 in 2024 - are served each year in shelters with shared bathrooms.
"They really need to put something up on the wall that says, 'Hey, if you have diarrhea, you need to go to hospital,'" Mosher said. "I don't know if they've had a meeting and told everybody that, because this is a 90-bed facility, and we're all packed in there, kind of tight."
Clark Center residents who report feeling ill are currently being offered priority appointments with health care providers, according to Clifton Roberts, spokesperson for Transition Projects, the nonprofit that runs the residential program.
"We have not had any additional reports of shigella in our facility, and we are monitoring the situation closely," Tony Bernal, chief executive officer at Transition Projects, wrote in an email last week. "We do have a standard procedure to regularly and frequently clean restrooms, showers, and other shared spaces -- including routine deep cleaning."
Since 2017, 44% of shigellosis cases recorded in Multnomah County where foreign travel was not a factor have occurred in people without stable housing, according to the county health department. Men who have sex with men and drug users are also overrepresented among the county's confirmed shigellosis cases. But the share of infections among homeless people has risen recently, according to health department officials.
"For the most recent clusters, 56% of cases have been among (people with unstable housing) and 55% of cases have reported methamphetamine and/or opiate usage," Sarah Dean, a spokesperson for the Multnomah County Health Department, wrote in an email.
One pandemic era innovation by the city to address the same issues - a lack of public toilets and a corresponding rise in shigella infections - was to place a slew of red portable toilets close to areas with a large number of homeless campers. At one point, the city maintained 123 portable toilets at a cost of $75,000 per month, but people living near where they were placed hated them, according to reporting by The Oregonian/OregonLive.
"Sinks and toilet paper dispensers have been stolen; units have been spray-painted, burned and tipped on their sides; and objects have been thrown in toilets, making them unusable," The Oregonian/OregonLive reported in December 2020.
In fact, every single unit was damaged in some way and 30 were deemed a total loss, according to The Oregonian/OregonLive report. In at least one incident, housed neighbors tried to physically stop city contractors from installing a new unit.
A city official with knowledge of the situation told The Oregonian/OregonLive last week that the vitriol incurred at the time meant it was unlikely that the city would put too many additional red portable toilets out at this point.
And using the existing infrastructure, like opening the closed-for-winter bathrooms maintained by Portland's Parks Bureau, isn't as simple as it might sound. The pipes for those facilities aren't winterized and could be at risk of bursting in a freeze, bureau spokesperson Mark Ross wrote in an email.
"An extensive systemwide evaluation of plumbing and infrastructure" would be required to determine what would be needed to keep parks bathrooms open in winter, Ross wrote. "This project would most certainly incur significant capital expense, and the bureau does not have funding for such an effort."
Parks officials have been saying for months that the bureau's programs and services are imperiled because inflation, rising wages and other factors continue to drive up costs. And city councilors delayed an effort to bring a new parks levy to the ballot for voter approval until November.
The species of the bacteria in circulation in Multnomah County are not among the most dangerous, according to the county health department. Infants, the elderly and the immunocompromised are at the highest risk for severe illness, Townes said.
Most people who become sick should drink lots of liquids, get plenty of rest, wash their hands regularly and avoid preparing food for others. Anyone with blood in their stool or who has had diarrhea for more than two days should contact a medical professional, according to medical advice from the nonprofit Mayo Clinic.
Antimicrobials, similar to antibiotics, are available in severe cases, but are not given in milder cases because several shigella bacteria are resistant to medication, which makes it harder to treat.
"That is a major concern," Townes said. "We can't just give antibiotics willy-nilly for these infections. If a patient is not very sick, the best thing is to isolate them and let it run its course."
Mosher started feeling sick several weeks ago, but didn't want to tell anyone because who wants to talk about uncontrollable diarrhea?
When it had gone on for two weeks, he finally went to the hospital and was diagnosed. The county health department put him up in a motel temporarily and provided food and cleaning supplies while he recovered. Mosher said he was grateful but bored in the motel room by himself.
The Multnomah County Health Department's communicable disease supportive housing pilot program started this summer with one-time funding of $337,033 for the current fiscal year. Most of that money goes to personnel, including a portion of a supervisor's salary. One dedicated staff member contacts people with a reportable illness, like whooping cough, Mpox or shigella, arranges their stay at a motel and then tries to help them find housing. The goal is to help 50 people by June and to limit the spread of infectious disease.
Since it began, the program has helped 24 people. Twenty of them had shigellosis.