Hep A, Homelessness: An emergent crisis

In 1854, London saw yet another deadly epidemic of cholera. London was burgeoning under the influence of the Industrial Revolution, but it’s medieval (literally) sewers, trash heaps, gutters, and under-your-house cesspools were overflowing with slaughterhouse offal, grease-rendering run-off, and market animal excrement. The city began dumping it’s unwanted filth into the Thames river which became smelly and dangerous.

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A political cartoon from 1852. See more here.

Many physicians, scientists, and politicians at the time believed that disease was transmitted by bad air–in particular, air putrefied by rotting matter (called the miasma theory). This wasn’t a totally stupid idea. Scientists of the time could observe fungus spores on their microscopes and could observe the close correlation between coughing and death. They could see the smoggy air out their windows and the filthy streets at their feet. Unfortunately, the cholera outbreaks continued persistently despite treatments of the time.

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Dr. Snow’s epidemic dot map. Red dots and blue faucets are a modern addition to make it easier to see the patterns. See the original black and white here.

Dr. John Snow (not that one), had another idea. He theorized that cholera was spread through water tainted with germs (the germ theory). When an extremely bad outbreak of cholera occurred in Soho (127 people died in three days), Dr. Snow with the help of Reverend Whitehead carefully interviewed the patients and the community members. He was able to identify what each of the patients had in common: a water pump. He took samples of the water, but it was inconclusive. He asked the city to take the handle off the pump. They did so and the infection seemed to decline. (In his journals, he is careful to note that the disease was already declining because people had fled when the outbreak occurred, but that taking off the handle did seem to help reduce the infection rate.) He carefully drew a dot map of all those who had died from cholera in the neighborhood and noticed an anomaly which further supported his water-borne theory. None of the employees from the Broad Street brewery got sick. As part of their wages, they were given beer to drink. And the water for the beer is boiled–killing the germ.

And that’s how modern epidemiology was born.

Today, much of the epidemiology work is done by the Center for Disease Control (CDC) and the World Health Organization (WHO). Like Dr. Snow, they monitor disease outbreaks, make recommendations, and respond to emergencies with vaccines or other appropriate care.

In March 2017, the CDC recorded an enormous spike in another disease, like cholera, spread by the fecal-oral transmission route: hepatitis A. Hepatitis A is a viral infection which targets the liver. It is spread by fecal contamination and is completely preventable by good hygiene (washing hands, drinking clean water) and vaccinations. It is most often found in places of crises with developing or destroyed infrastructure. So why was it showing up in San Diego, Salt Lake City, Detroit, and New York City?  The Huffington Post reports the CDC’s numbers in this terrific graphic.

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HuffPo crunched the numbers: hep A on the rise in 2017.

In San Fransisco, escalators were being shut down for cleaning. Excrement had piled up in the gears. In San Diego, feces on the sidewalks and streets were being dried and aerosolizing (becoming airborne). It became so bad that San Diego washed it’s streets with bleach and is scheduled to continue to do so every two weeks. Detroit saw a national record (post release of a vaccine) of 837 cases of hepatitis A–bad enough for the state health department to issue a travel warning. I could go on.

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NPR reports street cleaners using bleach in San Diego to combat Hep A outbreak.

If Dr. Snow’s observations have taught us anything, I think it’s taught us to look at outbreaks as warning sign of a city in crisis. Sick cities make people sick.

In this case, as the Washington Post (and others) posit, the crisis is homelessness. Hepatitis A outbreaks correlate to cities with the highest homelessness and drug-user populations (people who shared needles used to be the highest population of hep A patients in the 90’s but that has now changed). Homelessness is caused by many factors, but many in the Bay Area argue that the rise in housing costs coupled with a decline in public facilities caused this particular issue. Others argue that an increase in spending on public services has attracted homeless persons to these areas. But whatever the case, it remains, that the streets are unhealthy.

Additionally, the outbreaks have been hard to stem because the vaccine for hep A is a two-part dose administered several days apart. It can be difficult for health workers to follow up with homeless patients to get their second shot. This allowed the hep A outbreak–which would normally be contained by herd immunity–to get large enough to enter the broader population (only briefly, and to no great harm thanks to quick-acting responders).

On the other hand, the hep A outbreaks are (at least in San Diego) causing vulnerable homeless populations to become even more vulnerable as the city is taking a more proactive stance on arresting homeless people. The justification is two-fold: a) they need to move so that the city can wash the sidewalks and b) they are disproportionately falling ill due to unsanitary conditions. It might be better to remove them to a clean area for prevention and treatment.  In the meantime, the homeless want to know what will be done with them and their possessions now that they have been moved.

Fortunately, there is some good news. As of April 2018, the CDC reports the following:

With the slowdown in reported hepatitis A cases across California, CDPH has demobilized the outbreak response and continues to monitor reported hepatitis A cases statewide.

There is similar news from all the infected cities. Thanks to a history of epidemiology and the quick action of health-care professionals, we have quelled hepatitis A in our cities. For now.

Dr. John Snow’s research into cholera helped to inform London’s city planners decisions over time. The pump at fault was drawing water three feet from an underground cesspit which had begun to leak. Because of this and other incidents, we know how to keep our water and sewage separated.

What will these modern hep A outbreaks teach us about city planning?


Further Reading

 

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How to Census the Homeless

Last time, we talked about how Emergency Managers can contact vulnerable populations–for instance, the homeless–with evacuation notices. We discovered that social connections which make communities more resilient as a whole make the homeless in those communities more resilient too.

But as an Emergency Manager, I know that resilience often depends on the effects of long-term, complex social issues. For instance, Haiti sometimes finds it more difficult to recover from earthquakes than it’s sister country, the Dominican Republic, because Haiti is poorer, has non-resilient infrastructure, and social policies which (debatably) prevent economic recovery. Similarly, in America, policy discussions centering around social-political issues like homelessness impact the long-term resilience of a community to disasters.

Policy discussions are important and they rely heavily on statistics. As you know, fair representation in a community means being accurately counted. How can policy makers and advocates make decisions about policy and funding without a careful understanding of the demographics and size of a vulnerable population?  As you might imagine, counting a scattered and mobile population is extremely difficult. This article from the Seattle Times demonstrates how parsing the census data can greatly change the picture; depending on how you ask the question, Seattle has between the third and sixth most homeless in America.

The severity of Seattle’s homelessness crisis is different depending how you measure it — but no matter which way you look at it, we’re in the top 10 worst in the country.
Courtesy of the Seattle Times

 

So how do you count the homeless population in your town? In America, most cities choose to do an annual, night census of the homeless to get a sample.

Counting the unhoused once a year to get a sample.

Most cities have an annual, nightly census where volunteers physically visit known homelessness sites and gather demographic data from those sleeping outside. Sometimes this is accompanied by census data gathered from people using homelessness services. This method of data collection can be problematic for several reasons.

a) A yearly census may have data gaps. While it’s true a yearly census is good for trends over time, it gives only one snapshot of the homelessness situation on this night. Some argue that more frequent censuses would give granularity to the data.

b) Each jurisdiction and agency draw the geography differently. As the Seattle Time’s points out, because of the hodgepodge way each locale accesses funding, each city and county may count people differently. “New York City, for example, counts the homeless people inside its city limits while L.A. counts everyone in L.A. County except the cities of Pasadena, Glendale and Long Beach…. Denver and Boulder group together and count all the homeless people in the six counties around them….” This can make comparing data nationally–or even regionally–a headache.

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Pic courtesy of Associated Press

c) It doesn’t count those in shelters (sometimes, depending where you are). This isn’t necessarily a problem depending on what you want the census to tell you. Some cities, like New York are under legal mandate to house their homeless, so counting those strictly on the streets matters to them. But maybe your city wants to know more about how many people might need a certain governmental service. In that case, this statistic might not help you, beware.

d) It doesn’t count the “concealed homeless”–those living on a friend’s couch or in their cars. Like point c, this is a matter of semantics; neither good nor bad, but worth noting.

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Pic courtesy of San Bernardino Point in Time Count

Is crowdsourcing better? No matter what you do, it’s hard to get a clear estimation of “hidden” individuals. Cities are big and individuals are small. Crowdsourcing has helped gather data on large, complex problems before, maybe–the thinking goes–it can do the same here.

New York City has tried just that with their 311 app. Designed to accumulate citizen complaints for a variety of municipal problems, it was expanded to allow users to help identify the homeless. App-users can take geo-tagged pictures of the homeless and tag them with statements like “NeedsMedicalAid” or “AggressiveBegging”. Unfortunately, some homelessness advocates feel this app has led to shaming and harassment (especially–in my opinion–given that the complaints can be viewed by the public). (View the story here.)

On the other hand, a competing app in New York named “WeShelter” has a gentler image.  App-users “unlock” donations from sponsors which are given to several of New York’s homelessness organizations. Users have an opportunity to share their location with the app by clicking “I’m near a person who is homeless” and can also provide other information like whether or not the person needs non-emergency assistance. This is an interesting combination of location data gathering with activism. And there are many, many more apps with various methodologies out there.

GiveSafe Beacon. Pic courtesy of Smart Cities Council

In Seattle, an app called GiveSafe distributes beacons the size of a quarter to individuals in need. The beacon has a bluetooth that connects to an app on your phone. You can see the individual’s story as you pass them and also donate, if you wish to. The beacon holder can then spend the money at select merchants or non-profits. To keep the beacon active, the holder must keep in touch with a counselor once a month. It was designed hoping that donors would be more willing to donate if they could be assured that their money would be used to help with food (for example) and not vices. (See also StreetChange in Philidelphia & HandUp mostly everywhere)

 

Conclusion

Homelessness census data–like most statistics–are complex and variable. However, policy makers and municipalities rely on this data to distribute funding and reassess their policies. It’s up to us to make our statistics as robust and meaningful as possible in order to support that work. Often, that means gathering different kinds and sources of data to create a mosaic-like picture of the situation, and experimenting with data gathering methodologies.

Further Reading

How to Evacuate the Homeless

How do you find and evacuate the homeless if you need to?

It’s a question that’s been bothering me–and many city leaders–for a while now. Homeless people are often the most vulnerable and the most disconnected from “normal” information channels like TV and radio which makes them a population more likely to be hardest hit by a disaster.

I did some research and talked to some people and here’s what I found:

  1. The homeless are not as disconnected as I originally thought.
  2. Solutions designed to target other, related, homelessness problems can be adapted for emergency use (a pretty standard procedure for cities and states faced with limited resources)
  3. The most vulnerable of society (homeless and otherwise) will–no matter what–be the hardest hit during a disaster. But, the more prepared individual citizens and businesses are to take care of themselves, the more resilient the community, the more help is available to the most vulnerable of society when it’s needed most.

Connections Exist

According to the Atlantic, 75% of homeless youths use social media compared to 90% of their age-matched compatriots. While it is yet one tiny study, it led one researcher to posit that the Digital Divide may not be as large as we thought. Especially since the FCC (Federal Communications Commission) has been working to narrow that divide since 1985 via it’s “Lifeline” program which subsidizes landlines and cell phones to low income consumers. (By the way, both Forbes and Snopes both debunked the myth that these phones are free or paid for by taxes.)

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Picture courtesy of The Atlantic

Not only do some homeless have more access to cell phones and the internet (giving them a channel by which to receive evacuation notices) than I thought, but they are more socially connected than I imagined. This interview with Vacaville, CA Police Chief John Carl from the Armstrong and Getty Show shows how familiar the Police and other service providers get with homeless individuals. (I highly recommend a listen. It’s about 20 min long, but really interesting.) And some cities are working to make those social connections even stronger.

Connections build resiliency

Carli describes how his town created a “Homelessness Roundtable” to coordinate with private and public stakeholders/service providers. He also formed the “Community Response Unit”–a police unit designed to–among other things–get to know homeless individuals. CBS Sacramento has an interesting report on their successes.

 

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Photo courtesy of Seattle Navigation Teams

Likewise, Seattle has formed “Navigation Teams,” a combination of police personnel and social workers who spend all day everyday on the city streets, getting to know the individuals in the camps and offering them housing or other services. They report that after the institution of these teams, that the acceptance rate of housing offers went from 5% to 30%.

Furthermore, this news report alludes to one of the other benefits of these teams which is relevant to my question. When an infant disappeared into the vast network of homeless camps, the Navigation Team were asked to help find her. Because of the knowledge and trust they had earned with their daily engagement, they were able to leverage the homeless network to find the child. This is the true power of these Community Response Units and Navigation Teams: they can be tapped to deliver disaster warnings to those that might otherwise miss it.

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Homeless camp on I-5 near the Capitol Hill neighborhood of Seattle. Some encampments are especially close to the dangers of traffic.

In fact, it has already happened on a small scale. I spoke to the Seattle Office of Emergency Management spokesperson who mentioned to me that shortly after the Navigation Teams had begun working, a tanker overturned on I-5. The police used the brand new Navigation Team maps of homeless encampments to evacuate the homeless in the area. (He didn’t tell me a specific date, but I think this is the news report.) Navigation Teams and Community Response Units are designed to help the problems surrounding homelessness, but they may be a crucial link when it comes to delivering disaster warnings. I’d love to see Navigation Teams in every city.

Finally,

I can’t help but notice a lesson buried here: when we work to make our communities safer and healthier, we make them more resilient as well. The homeless may be especially vulnerable, but–exactly like the rest of us–when they have more connections, they are more resilient.

Further Reading

The State of Flooding in America

The American Society of Civil Engineers (ASCE) estimates that 40% of Americans live or work near a levee. The average age of these levees are 55 years (some as old as 100 yrs) and they have worked to protect over $141 billion in flood damages–a 6:1 return on investment (24:1 on the Mississippi River and tributaries).

However, over the last 50-100 years, we have significantly developed floodplains lands, experienced sea level rise, and neglected the maintenance of these levees. ASCE gives the national levee infrastructure a D- grade (very poor). Grades are based on capacity, condition, funding, future needs, operation/maintenance, public safety, resilience (how well they withstand disasters), and innovation.

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Pump maintenance crews, NPR

It’s not only levees that protect land from floods. And it’s not only levees that are aging nationally.

  • Bridges: C+
  • Dams: D
  • Inland Waterways: D
  • Levees: D-
  • Roads: D (get flooded)
  • Wastewater management: D (pipes, sewers, storm water drains, etc.)

Every facet of our storm water management system is dismally graded meaning that Americans all over are at risk from an aging, failing infrastructure. (See the full report card here)

This autumn has seen an historical amount of rain in the midwest as an unusually warm El Nino cycle takes charge of North American weather. Illinois and Missouri have logged about 10 inches of rain over three days causing the Mississippi, Missouri rivers and tributaries to flood. Officials down south are watching carefully as Mississippi flood water is scheduled to hit the brand new New Orleans levees in about a week (Jan. 9, 2016).

The State of Flooding in America
2016, Flooding in midwest raises questions about infrastructure. Especially in New Orleans where the new levees are being completed. | EMScholar

 

After Hurricane Katrina (2011), the US Army Corps of Engineers was authorized to spend about $14.6 billion to strengthen levee walls, build massive flood gates, install cool new flood modeling computers, and update the city’s water pumps (according to CNBC and NPR). But, as the Engineer Corps is wont to warn, new infrastructure doesn’t necessarily assure safety. New Orleans is a fishbowl. We can build lots of walls, but water will always need to go somewhere–a sentiment that Bob Criss Professor of geology at Washington University expresses in the Journal of Earth Science.

“The Mississippi River should not be going crazy after three days of rain,” Criss said in an interview. The problem, he believes, is that we’ve walled off rivers without thinking about a release for the water. It’s Downstream City’s problem. The Army Corps of Engineers has long agreed, stating that the Mississippi River and it’s tributaries (and–presumably–by extension all river systems) should be connected “more naturally” with the flood plains. This means undeveloping the flood plains.

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Midwestern flooding, 2015, NPR

The combination of failing infrastructure with poor long term flood management planning has caused experts from many fields to call the Federal government to reimagine national flood policy.

Current national policy is based on insurance policy statistics. You may have heard the term “100-year” or “500- year” flood or storm. A “100-year storm”is a storm of such a size that it’s chances of happening in any given year are 1%. Depending on who you ask, Hurricane Katrina was a 100-year storm. However,

 The 100-year threshold is also a statistical guess based on data on past storms and assessments of whether they’ll occur in the future. That means the models change every time a new hurricane strikes. The numbers being used as guidelines for construction are changing as time passes.

And, as an engineer working on New Orleans levees points out, the current levees were meant to protect city infrastructure. Residents shouldn’t depend upon them to protect lives. There’s always the chance that a bigger storm will come along.

Thousands of miles away, Washington State–well known for it’s rain–is also struggling with flooding. Unusual amounts of snow in the Olympics combined with lots of rain caused flooding along the coast. Enough flooding to open the Emergency Operation’s Center which stymied this researcher’s thesis by causing the people she needed to be busy. (“Graduation postponed on account of rain,” she lamented on social media.) It’s not just the rain. In fact, 2015 was actually a drier than normal year. It’s that Washington coast is built for moderate, continual rains. Not for cycles of drenching rains and drought. The Washington State Climatology Office believes that this rain-drought cycling is a direct result of global warming and won’t get better. Just like how bigger storms are becoming more regular. Global warming is causing extremes of all sorts.

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WA, Snoqualmie Falls: normal water flow on 10/23/15 and after rains just a week later on 11/1/15. (Photos by Richard, Krisha Chiu. Found here.)

What can be done?

The ASCE has a “tell your legislator” form and ways to share the news on their report card website (scroll down). We need to pressure local and federal governments to make decisions based on new data and the long view. But even more importantly, as citizens, we need to accept taxes which pay for infrastructure. In New Orleans, the city is fighting with the feds over who will pay to maintain the new levees. Voters have twice declined to raise taxes to pay for it. One frustrated official exclaims,

“We’re talking about $5 a month to the average taxpayer. That’s a six-pack. That’s a pound of crawfish in April…This is a country that’s run by the citizens. The citizens decide they don’t want to have flood protection, then we’re not going to have flood protection.”

I am not advocating for blind acceptance of every new tax hike. Like responsible people, we need to watch where our money goes. We should buy things with our taxes that are “worth it”, that is: effective, efficient, and high quality. We also need to watch that our towns and cities use our taxes the way they promised.

That seems like a lot of work. But maybe it’s worth it for keeping your house dry and your water clean.

Further Reading

 

An Unusual Winter: Boston’s trouble with Emergence

A man drags a shovel up Beacon Hill during a severe winter snow storm in Boston
Photo courtesy of Boston.com

This has been an interesting winter for Boston. Yes, lots of other places have had just as bad–or even worse–conditions and I don’t want to minimize that. But Boston has unique problems.

Shouldn’t they have been prepared?

I mean–winter’s happen every year. And every year, Boston has to deal with snow. What’s the big deal? Homeland Security Watch has this to say,

“Boston is a city that can handle a snowstorm.  Indeed, it can handle any single blizzard.  What is causing problems is the quick succession of substantial snow storms in the past month, along with sub-freezing temperatures preventing melting, that has slowly choked the transportation arteries of this densely built city.  This is leading to an unfortunate set of cascading outcomes that normally would not be a concern during normal winter weather.”

From the outside, it looks like Boston is simply incompetent, when the truth is that this is not a normal problem. It is what Harvard professors Dutch Leonard and Arn Howitt refer to as an “emergent crisis.” Emergent crises are especially hard to recognize and treat for 3 reasons.

  1. They look like normal problems. Boston has had snow before. This is a normal problem and has a normal response: plowing.
  2. Since they look like normal problems, the experts sent to deal with it, tend to get tunnel vision. Leonard & Howitt state, “Often, experts (and, perhaps even more so, teams of experts) are not adept at recognizing that their approach is not working. Often, they ignore “disconfirming evidence” (i.e., the flow of data tending to show that what they are doing is not working) and “escalate commitment” to their existing approach. The person or team working on the situation may not only believe that they are about to succeed (with just a little more effort and time) but also feel pressure not to lose face if they fail to handle the assigned situation.”
  3. Finally, emergent crises are especially difficult to treat because they have all of the qualities of a non-standard emergency (…”the difficulty of recognizing novelty, the challenge of creativity and improvisation of new approaches and designs under stress…”), with already deployed teams not trained in this kind of emergency. It can be hard to convince organizations already working on the problem to shift gears.

In a broader sense, emergent crises are a good example of how hard it is for responders to recognize data from noise. As I wrote here, one of the main jobs of cities, organizations, individuals, etc is to process information from the environment. More often than not, the information is meaningless (you don’t care that your shirt is touching your shoulder), but sometimes it matters (if your shirt is caught in a corn husker, suddenly you care it’s on you). But knowing what is important and what isn’t is extremely difficult since we generally don’t have the big picture or know the future (by the way, that’s why teams are so useful–each person holds a different part of the picture. Working together makes it easier to do stuff right.).

So what do we do?

Well… nothing. The human condition is such that we will always struggle a little bit to recognize new problems. But I think there’s a Communications theory that can help a little. It’s called Groupthink– you may have heard of this already. Essentially, when groups value consensus, they tend to ignore data which opposes or contravenes  their decisions and plans. Group Think could be complicating the emergent crisis/data-noise problem. But there is a solution: diversity. When groups value contrary opinions, they avoid tunnel vision and are much more successful at recognizing emergent problems.

Further reading