Blog note: this article, along with several previously posted articles, references many grand jury reports addressing the subject.
Three people were dead by the time San Diego County public health officials organized street teams to offer vaccinations against hepatitis A. It was early May and 80 cases had been confirmed since November, with 66 patients hospitalized.
Epidemiologists had first identified the rash of hepatitis A two months earlier.
Dr. Wilma Wooten, the county public health officer, put off declaring a local emergency until September, when 14 deaths were recorded and the patient rolls of mostly homeless people and illegal-drug users surpassed 350.
The same day, a Friday morning three weeks ago, Mayor Kevin Faulconer issued his first public statement on what has exploded into the the nation’s biggest hepatitis A outbreak in years.
Faulconer’s news release from Sept. 1 announced that free vaccinations at the downtown library would be given out the third Tuesday of each month. He pledged to bleach-clean streets and sidewalks to help contain the infectious disease, although he said that would take time.
The San Diego mayor also deferred responsibility for the outbreak to San Diego County.
“The city continues to stand ready to support the county’s Health and Human Services Agency in its plans to provide vaccination, sanitation and education to San Diegans as we battle this outbreak,” Faulconer said. “We must continue to work collaboratively to stop this crisis and save lives.”
Leaders from the city and county watched while the casualties piled up.
Last week, at a joint news conference, officials from both agencies warned that more lives are at risk, and the crisis may persist into spring. They pushed the death toll to 16 and said nearly 450 cases were confirmed. Two other fatalities were suspected hepatitis A cases.
The stepped-up attention that the outbreak has received in recent weeks is welcome news to activists and medical experts.
But many see the crisis as the inevitable result of San Diego officials’ longstanding failure to deal with problems besetting the homeless community and working-poor families. They point to local government’s lackadaisical response to the outbreak as a prime example.
“This whole crisis is man-made,” said Michael McConnell, a La Jolla coin dealer and advocate for homeless residents. “The response is certainly much too late, based on when they knew they had a serious problem. Even today, all they’ve done is the most easy stuff. They have taken zero bold action.”
By bold action, McConnell meant opening more public bathrooms in East Village, the downtown community hardest-hit by hepatitis A. He pointed to foot-dragging in setting up hand-washing stations and a broader failure to confront homelessness or solve the affordable housing crisis.
“The city has failed in the worst possible way,” McConnell said. “The city and the county have failed in the worst possible way.”
Local officials say they have done a responsible job under difficult circumstances.
They notified clinics as early as March 10 and launched an awareness campaign. By April they organized vaccinations at shelters and churches where homeless people congregate. They consulted with the U.S. Centers for Disease Control and Prevention for help and guidance.
“No one with the county of San Diego dragged their feet,” county spokesman Michael Workman said. “This at-risk population is a major challenge to waging a vaccination campaign.”
Workman said many people vulnerable to hepatitis A — homeless people and illegal drug abusers in particular — fear or do not trust government authorities, even nurses offering vaccine.
“You have to go in to the alleyways and underpass encampments to make contact with all who do not frequent shelters,” he said.
Mayoral spokesman Craig Gustafson said Faulconer has committed to attacking homelessness as strongly as he has to expanding the convention center or luring professional soccer to San Diego.
“In January’s State of the City address, Mayor Faulconer declared the homeless crisis the city’s No. 1 social service priority,” Gustafson said. “He then proposed a ballot measure that would have created an annual dedicated funding stream of $10 million for homeless services, which the council majority voted against.”
The public health threat now confronting city and county officials was predicted long ago.
Political leaders were warned repeatedly that an outbreak like the hepatitis A crisis might happen if they did not deal more forcefully with housing, sanitation and other basic functions of local government. Critics say little to nothing was done and, in some cases, government policies and practices made things worse.
Hepatitis A has been almost entirely preventable since 1995, when federal regulators approved a newly developed vaccine for widespread use.
The disease that regularly infected tens of thousands of people a year was all but wiped out within two decades. In 2015, the most recent year for which federal data are available, 1,390 cases were reported in the United States, 179 of those in California.
Critical to fighting the communicable disease is proper sanitation and access to bathrooms — two things San Diego repeatedly has been called out for lacking.
Two years ago, the county grand jury warned San Diego it needed more public toilets downtown. The city agreed with the finding but did not act because “there are competing needs for limited funds.”
Instead, the mayor and council president said the issue required further study. They even rejected the jury’s proposal to add signs alerting people to places they could relieve themselves.
“There is currently no funding identified in Fiscal Year 2016 to install or maintain signage specifically for public restrooms,” they wrote.
An earlier grand jury said the Sheriff’s Department should do more to protect the health of jail inmates, many of whom are on and off the streets where the homeless gather. In 2013, the citizens panel criticized the county for failing to provide regular screenings and immunizations, including for hepatitis A.
“Public health and correctional professionals now recognize the significance of including incarcerated populations in community-based disease prevention and control strategies,” the jury wrote in bold letters.
County Chief Administrative Officer Helen Robbins-Meyer and Sheriff Bill Gore disagreed with the findings and rejected the recommendations.
“The San Diego Sheriff’s Department is in compliance with applicable standards, which are found in Title 15 of the California Code or Regulations,” they wrote. “Immunizations that are currently offered to jail inmates are consistent with other county jails.”
Sheriff’s spokesman Ryan Keim said last week that there is no correlation between the department’s response and the current hepatitis A outbreak.
“The grand jury report and CDC guidelines did not recommend hepatitis A vaccine to all inmates, and subsequently would not likely have made an impact on the current hepatitis A outbreak,” he said in a statement.
Keim said the department studied the jail population in recent weeks to see which inmates were at greatest risk for hepatitis A and recommended vaccinations, which are voluntary. They persuaded more than 2,300 detainees to get treated.
So far, 21 inmates have been diagnosed with hepatitis A, including five people who contracted the sickness while in custody.
Tackling the outbreak has been especially difficult because the virus is transmitted person-to-person rather than by a common food source, like a restaurant worker, that could be identified and contained.
The infectious period stretches from 15 to 50 days. That means symptoms — fever, nausea, jaundice — may not show up for weeks, or at all. People may not know they are infected.
Beyond access to bathrooms, the underlying cause of the hepatitis A outbreak is an affordable housing crisis that has bedeviled the city for 15-plus years.
In January, the Regional Task Force on the Homeless counted 5,621 unsheltered people in San Diego, a 14 percent increase over 2016.
The downtown homeless population swelled 27 percent over the same period, to nearly 1,300 people. Many of them camp in tents or makeshift shelters on city streets, and become the subject of enforcement by San Diego police. Near-daily sweeps have pushed more homeless people into fewer spaces, which exacerbates sanitation problems.
“The reason the outbreak has spread so rapidly is because homeless are living in more concentrated areas,” said Dr. Jeffrey Norris, the St. Vincent De Paul medical director who has been managing the charity’s response to the public health threat. “They often have to defecate in their tent, or next to their tent, and that exposes their neighbors on the street. Hygiene becomes incredibly difficulty.”
San Diego banned plastic grocery bags last year, taking away a manageable alternative to defecating outside a bathroom. County health workers are now handing out thousands of “hygiene kits” that include plastic bags.
Historically, the city has struggled to adopt policies that promote affordable housing and aid homeless residents. Year after year, the mayor and council discuss solutions but fail to adopt more than incremental changes.
Sometimes public officials undermine the very communities they are supposed to help.
The city Housing Commission, for example, allowed more than 10,000 hotel rooms and other affordable units to be removed from the housing stock between 2010 and 2016, The San Diego Union-Tribune reported last year.
The lost housing is roughly equal to the number of new dwellings the agency created since 1979. The commission spent billions of tax dollars in recent years; its 2017 budget is $368 million.
Months after being elected mayor, Faulconer closed out a years-old program that used large tents to shelter hundreds of homeless people through cold winter months. He said he was focusing on a “housing first” model successfully implemented in other cities.
Earlier this month, Faulconer announced he would accept help from two businessmen who raised $1.5 million in private funding to reopen the tents.
“We are in a crisis that calls for action,” he said at a Sept. 13 news conference.
Jim Lovell is executive director of the Third Avenue Charitable Organization, a small nonprofit that provides meals and medical checkups to needy people in downtown San Diego.
One of his biggest worries, Lovell said, is that better-off residents will blame poor people for the deadly health threat that may have been avoided with smarter government.
“We’re still talking about urination and defecation as if it’s a problem caused by homeless people,” he said. “You can’t just have people outside, not provide facilities and expect all to be well.”
September 23, 2017
The San Diego Union-Tribune
By Jeff McDonald
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