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.

a_court_for_king_cholera
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.

snowmap_points
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.

5aaad6941f0000150316a843
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.

spray-951d3fc68db8457c0ca6ee1f7381718d219e5bd6-s800-c85
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

 

Advertisements

Further Reading: Cascadia Rising in the News

cascadiarising_banner1

This is part of a series about the largest disaster exercise conducted in Washington State history called Cascadia Rising, 2016. See the other blogs here.

Here’s some articles I found with another perspective on Cascadia Rising.

  • FEMA Headquarters did a fun live-blog for the duration. They asked bloggers from different areas of the response to post photos and write a few sentences. (Yours truly was featured a couple of times, too.)
  • A very thorough account of how an earthquake/tsunami would affect the Puget Sound area as well as details about the players in Tacoma. Check out the beautiful map.
  • A story done about the Navy and National Guard practicing in the field with real paratroop drops, docking vessels, and helicopter fly-overs. I was told that both the military and national guard were doing their own training concurrently with Cascadia Rising, but I was unable to ask more about it. Glad to have seen this story to get another perspective!
  • Really  nice overview of the exercise with quotes from around the state and beautiful pictures from the Seattle Times.
  • More details about National Guard maneuvers on Vashon Island and an interesting tidbit on how the local radio station also played along with the Exercise.
  • The Navy and Coastguard practice building docks to deliver supplies at Port Townsend, Port Angeles and others. During this kind of event, one of the best ways to deliver help will be via water. The military has both super cool tech and super cool expertise.
  • Behind the scenes look at a county Emergency Operations Center. Another facet I was unable to see first hand. Interesting!
  • The National Guard build tent city in Mason County. Governor Inslee visits.
  • Describing Idaho’s involvement.

Cascadia in the News

Preliminarry Lessons Learned and After Action Reports

General Info about Earthquakes and Tsunamis in this area

Preparedness Links:

What Membranes and Pendulums Have in Common.

Finding balance

I briefly considered being a therapist in High School. I’m a good listener and fairly analytic, so it seemed like a good fit until my mom said, “Yes, but you’d have to keep your distance.” My mom knew that I have a lot of empathy and sometimes have trouble not getting emotionally involved in other people’s problems. (Just like she knew that my 6 y/o self would have a hard time putting animals to sleep if I grew up to be a veterinarian. Which I proclaimed was fine, because I’d bring all the animals to live with me. And she just nodded–bless her.)

Both of my parents are medical doctors, so I was familiar with the “shell” that doctors have to develop so they aren’t emotionally traumatized every time a patient dies. Like army commanders, they have to maintain some distance from their patients so that they can continue to do their work when bad things happen. As I began my Emergency Management studies, I assumed that I would have to develop a similar shell. I assumed that I would become cynical and jaded, like Dr. House on his eponymous show. But I don’t want to be that person. The whole reason I became an Emergency Manager was to help people and how can I continue to do my job well if I lose my humanity?

DrHouseQuote

But this week, I noticed something else. Instead of developing a hard shell so that all the stories about child trafficking, suicide bombings, and Russian poverty don’t bother me, I’ve developed a permeable membrane. These stories still bother me a great deal. So, I take them in small doses. I follow world events thoughtfully–sometimes carefully avoiding a particular story while at other times purposefully following others. I monitor my emotional state frequently and when I feel stressed, I focus on happy things. When I feel robust, I check in with the world. (It never changes much.)

But in order to do this, I have to put aside the embarrassment and shame of not keeping close tabs on current events. I have to stop cringing every time someone gasps, “You didn’t hear about that?! Where have you been, under a rock?” I have to practice saying, “I didn’t have the emotional fortitude for that story.”–or perhaps something better. Something that conveys that I don’t consider world events entertaining. That I take human suffering seriously–that it impacts me. That in order to do my job, I have to let it impact me and that I have to protect myself from its impact. And that that dichotomy is a balancing act that seems more like wavering between two extremes rather than a perfect moderation.

As my mother told me once, “pendulums are balanced too”.

How do YOU manage your humanity in a world where bad things happen? Share below.