Dr. Drew Warns Of Plague Outbreak: How The Homeless Crisis Puts Los Angeles At Risk of Norovirus, Typhus, and Rickettsial Infections

Sept. 12, 2018 – By Michelle Poe and Dr. Drew Pinsky

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Humanity has experienced many deadly epidemics and pandemics during the course of history.  Millions perished as a result of the Black Plague, which decimated fourteenth century Europe.  Cholera arrived in England in 1831 and ultimately killed more than fifty thousand people before it ran its course.  The Plague of Athens, which occurred in Greece in 430BC (and killed the prominent statesman, Pericles), was likely caused by typhus.  Soldiers of the American Civil War were victims of many deadly diseases including cholera, dysentery and typhus.

These examples are culled from ancient history, and such catastrophic epidemics seem impossible (and perhaps even outdated) nowadays, but these germs are alive and well.  The Centers for Disease Control reports that 2.9 million people come down with cholera annually and typhus still infects thousands of people each year as well.  These diseases are transmitted by infected rodents, fleas and body lice.  The advent of modern conveniences like urban sanitation protocols and the development of effective antibiotics largely keep these illnesses at bay, but society is most certainly prone to fits of denial when it comes to the possibility of being infected by these dangerous bugs.

“8000 rats had been collected, a wave of something like panic swept the town.”

Albert Camus – The Plague

The average citizen can’t be blamed for feeling impervious to these old-fashioned sounding illnesses, but this is merely a false sense of security.  These diseases may initially arise in unsanitary conditions that are the norm of modern-day homeless encampments, but the germs that cause them are not selective about who they colonize.  It’s as simple as an infected flea making its way onto a house pet.  Even the most pedigreed, well-cared-for animals are at risk – and once they’ve made their way into the household all bets are off.  Volatilized viruses are extremely dangerous and, unchecked, can spread very quickly.  Super bugs that are resistant to antimicrobial drugs are also a growing problem.  Illnesses that come from these sources are difficult to contain and can be deadly. The commonly held opinion that we are removed from the possibility of an epidemic is simply a myth.

“These sites are just littered with tons of trash, human waste, feces, female products.”

– Mark Fragoso, Bargaining Unit Coordinator, Southern California International Union of Operating Engineers

It has been said that death and taxes are the only certainties in life, but Los Angeles sanitation workers may beg to differ.  Homeless people who defecate in public spaces is an ongoing crisis in county areas that have large homeless populations, and cleaning up after them has become a never ending feature of their daily routines.  Even CalTrans workers, who have completely different job responsibilities, are now tasked with shouldering a portion of this unenviable activity.  Claiming that they “didn’t sign up for this,” the union recently filed a grievance, stating that picking up hypodermic needles and human waste is not in the job description.

While Los Angeles, San Diego and San Francisco currently deal with large populations of homeless people, the problem isn’t confined only to metropolitan areas.  Los Angeles Mayor Eric Garcetti has made dealing with these issues a priority, but managing human waste is a challenging job and one that has evolved over time.

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For citizens of Colonial America, going to the bathroom meant using privies, or outhouses. These generally had outlets at ground level, which allowed for human waste to exit into the yard, street, gutter or open channels, which served as crude sewers. Sometimes a container directly under the toilet would store waste until it soaked into the ground or was removed. Needless to say, these structures were far from hygienic and washing with soap and water afterwards was unheard of. Lacking any real infrastructure for disposal of human waste, people generally lived with the inconvenience of these methods and took little notice unless there was an outbreak of disease.

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Since the 1800s, the United States has utilized many strategies to manage wastewater in urban areas, but they can be broken down into two main categories:

Centralized Systems:  Waste is collected on site and then removed to a central location for treatment or disposal.

Decentralized Systems:  Waste is treated and disposed of on or near the source.

The nineteenth century ushered in an era of rudimentary sewer systems (including underground versions), which were generally poorly constructed. Cholera epidemics (and other outbreaks) spurred the desire to improve sanitation practices, and by 1844, there were a growing number of ordinances that controlled how much water could be used and how wastewater was to be disposed. By the middle of the nineteenth century, most major cities had constructed water supply systems that piped water directly into the home. This improved the standard of living, but increased the amount of fecal matter that was discharged with wastewater as well as the risk of an outbreak. Despite these advances, water supplies were often contaminated. Effective methods of transporting this waste led to the construction of water carriage sewer systems.

During this time there were two main schools of thought regarding the transmission of disease. The miasmic theory of disease etiology held that invisible airborne vapors emanating from rotting organic material caused disease, and the contagionist theory purported that contact with microscopic organisms spread disease. This was a precursor to “germ theory,” which would eventually be proven by Robert Koch.

In 1849, Dr. John Snow, one of the fathers of modern epidemiology, published his theory “On the Mode of Communication of Cholera,” which outlined his belief about how the disease was transmitted. He confirmed his hypothesis when he successfully traced a cholera outbreak in London to a public water pump. This discovery led to the development of more sophisticated sewer systems. The U.S. followed suit and began to widely implement centralized water carriage systems. In 1871, the U.S. began to filter water (to remove germs) and chlorinate it (to kill disease-causing bacteria).

Early in the twentieth century, the need for proper wastewater management led to the development of cost effective strategies, including large scale activated sludge treatment. This is a process that uses micro-organisms to feed on organic contaminants in wastewater. As they grow, particles clump together (this is called floc) and then they settle at the bottom of the tank, leaving a relatively clear liquid that is free of organic material and suspended solids.

After World War II, economic expansion coincided with the arrival of new, water-hungry household appliances like dishwashers, clothing washers and sink disposals. These not only increased the volume of wastewater, but changed its composition as well. In response to the blatant pollution of the nation’s streams, rivers and lakes, Congress enacted the Water Pollution Control Act of 1948. This was the federal government’s first major law designed to address water pollution. The law was rewritten in 1972, and included new regulations for agricultural and industrial polluters. It also set the goal of eliminating all water pollution by 1985. The most recent major legislation came in the form of The Water Resources and Reform Development Act of 2014, which President Barack Obama signed into law that same year. It is an act that is intended “to provide for improvements to the rivers and harbors of the United States, to provide for the conservation and development of water and related resources, and for other purposes.”

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Modern day sanitation practices have certainly advanced how society deals with human waste, but this is only when it is disposed of properly. The homeless population (many of whom are dealing with varying degrees of mental illness, drug problems, or both) often camp or congregate in areas where there is inadequate access to bathrooms and fresh water supply. This combination results in large numbers of people defecating in public spaces, which sets up the potential for easy transmission of illness and disease. A recent survey of Los Angeles’
Skid Row found that there were only nine public toilets for 1777 people, and these were mostly inaccessible during overnight periods.

It has been estimated that fifty thousand homeless people live on the streets of Los Angeles, and despite Mayor Garcetti’s vociferous commitment to this issue, the number has increased since he took office in 2013. Also noteworthy is that the number of homeless people with mental illness increased by twenty-eight percent from 2015 to 2017.

Where is the disconnect?

Oftentimes the face of homelessness is depicted as someone who is simply down on his luck – the victim of a cascade of unfortunate circumstances that led to life on the streets. But this portrayal is more likely the exception than the rule. The overwhelming majority of people who live on the streets are dealing with drug addiction, mental illness – or both, which is why getting control of the issue is so challenging. Many homeless people are unwilling or unable to receive proper care, because they are held captive by their own delusions. They lack insight about their conditions and cannot appreciate that they are suffering from illness. These thought disorders create distrust, paranoia and fear, which manifests in a refusal to take advantage of shelters and other resources – despite community outreach. It’s not as simple as getting them into housing or signing them up for rehabilitative programs. Case in point: A 2017 review of sixty shelters found that more than half were not filling their beds.

This is a complex and multi-faceted problem, and there are a host of issues that must be addressed very thoughtfully (and over an extended period of time) in order to effectively assist the majority of these people.

In an article written for the Associated Press in December, 2017, writer Julie Watson quotes a resident of a city-sanctioned encampment located in a parking lot in San Diego. “It’s peaceful here,” said the pregnant mom of six children who also resided there with her. She stated that she preferred living in the tent rather than a homeless shelter. “There’s coffee first thing in the morning. We can hang out here in the daytime. I mean what more could you ask for.”

This brings us to the touchy subject of forcing treatment on people who might not be amenable to the process. Do we, as a society, have the right to force people into programs – even if they don’t want to participate? What about the safety of minor children who are homeless? Where is the line between civil rights and public safety to be drawn? The law does allow for involuntary commitment, but the bar is very high, which makes this a difficult process. Dr. Jonathan Sherin, Director of the Los Angeles County Department of Mental Health, is in the trenches when it comes to this issue. In January of this year, he sent a letter to the L.A. County Board of Supervisors recommending that they ask legislators to expand the criteria for those deemed “gravely disabled.” His goal is to lawfully expand the roles of social workers and law enforcement so that people who cannot provide for their own basic needs can be detained and helped. The board voted 4-1 in favor of pressing for legislation. Opponents argue that this could be a slippery slope, but short of having the legal wherewithal to force these services on those who clearly need them, there is little that can be done to mitigate the situation. Most people agree that criminalizing the homeless isn’t the answer, but many states are currently considering legalizing involuntary commitment for drug addicts.

Plagues – Then and Now

From 1992 to 2015 a replica statue of the water pump responsible for one of London’s massive cholera outbreaks stood on Broad Street as a silent reminder of the deadly epidemic.  Dr. John Snow, who identified the infected water source, was able to pinpoint its origin by creating detailed dot maps that specified the exact locations of its victims.  In a modern day version, Jenn Wong, a San Francisco software engineer, endeavored to raise awareness about homelessness in her city by creating Human Wasteland, a map detailing reports of human waste sites in the city over a period of seven years.  The map was updated monthly and indicates the location of each “incident” with a poop emoji (see it here: http://mochimachine.org/wasteland/).

Despite the fact that sanitation practices and wastewater management have improved immeasurably since those Colonial era privies, there are still outbreaks of disease caused by human fecal matter. San Diego, which bills itself as “America’s Finest City,” is currently a hotbed of illness caused by homeless encampments. In 2017, it was ground zero for a massive outbreak of Hepatitis A, which eventually worked its way up to Santa Cruz, causing Governor Jerry Brown to declare a state of emergency in October. As of January of this year, there were 577 confirmed cases, including 20 deaths, and nearly 400 hospitalizations.

In February of this year, Orange County officials evicted more than 700 people from a three-mile long homeless encampment on the banks of the Santa Ana River. The cleanup involved the removal of 1000 pounds of human waste, 5000 needles and 250 tons of trash. It’s easy to understand how disease springs from these squalid conditions. Crowded, filthy encampments are largely devoid of proper hygiene practices. This combined with inadequate or inaccessible bathroom facilities make their populations particularly vulnerable to viral and bacterial infections that spread via improperly disposed fecal matter. In addition to Hepatitis A, streptococcus, shigella and tuberculosis are also linked to homelessness. Norovirus, a highly contagious illness that causes vomiting and diarrhea is also transmitted through infected feces. Rickettsial illnesses such as murine typhus and Rocky Mountain spotted fever are transmitted by fleas, mice, ticks and mites, which may also thrive in less sanitary environments. This means that any pet that comes into contact with an infected flea can carry the disease home to its owners. Compounding these problems is the fact that the homeless population has less access to health care systems and treatment, so not only are they more vulnerable to disease spread by uncontained human waste, but they are also more prone to illnesses like influenza, strep throat and sexually transmitted diseases.

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The Los Angeles sewer system carries wastewater to one of four water reclamation plants where is it treated before being discharged into the ocean or the river. LASAN (Los Angeles Sanitation) operates and maintains the largest water collection and treatment systems in the United States, serving a population of four million. The city has four cleanup programs to manage the homeless situation. Operation Healthy Streets–Skid Row and Operation Healthy Streets–Venice are dedicated to regular and frequent cleanups in these areas. Clean Streets LA handles citywide cleanups of illegally dumped trash and encampments and HOPE (Homeless Outreach and Proactive Engagement) brings the LAPD, sanitation crew and outreach workers together to handle more sensitive encampment cleanups. Sometimes these methods can seem barbaric or outdated (the streets of Venice are routinely washed down with a bleach solution to combat the germs found in human feces) and can add to the indignity of being homeless.

Cleanup efforts are necessary and admirable, but it is nearly impossible to address the countless components that contribute to the making of each person’s situation. When encampments are removed, disenfranchised populations are further displaced and disgruntled. Unfortunately, they often migrate to areas where they are unwelcome. Business owners are burdened with vagrants who loiter and want to use bathroom facilities and disagreements ensue.

Infectious disease expert and public health scientist, Dr. Michael Osterholm sites several pillars of the public health system that provide for a strong defense against illness and disease. They include chlorination of the water supply, vaccination and pasteurization. If one of the system’s pillars fails, problems will ensue.

Homelessness, mental illness, poor sanitation, lack of access to clean public bathrooms and poor hygiene are all major contributing factors to the spread of illness and disease. This is a complicated problem that must be addressed from many different angles and by many different agencies – but at its base seems to be the issue of mental illness. Until society develops effective methods for treating people who suffer from these disorders, it is unlikely that any real improvement will occur. Each person who suffers from mental illness comes with his/her own set of circumstances and requires individualized treatment. The addition of an addiction complicates things even more. This is a costly, time-consuming process that demands a dedicated army of professionals from every medical discipline, an endless array of social services, assistance from law enforcement agencies and community commitment. And even when all the stars line up there is no guarantee of success.

“I have no idea what’s awaiting me, or what will happen when this all ends. For the moment I know this: there are sick people and they need curing.”

– Albert Camus – The Plague

Healthy sanitation practices are not the priority of a homeless person who suffers from a mental health disorder, a drug problem or both. Because the criteria for forcefully detaining people with these issues is notoriously difficult to satisfy, legions are left to suffer in the streets. Individuals stricken with physical illness, are picked up and hospitalized, but mental illness represents the great divide when it comes to mandatory treatment. Have we, as a society, forsaken this population? Are we content to stand by and allow civilization to deteriorate to the point where the “pillars of health” are pushed to their limits or even destroyed? This is not a problem that will solve itself; the homeless population has neither the ability nor the wherewithal to mobilize against it. The chronically ill must be given considerations that most of us do not require. Whether it’s expanding the conservatorship laws, forcefully treating people or implementing new systems altogether, action must be taken. Ignorance of this issue is short-sighted and potentially very dangerous to life as we know it.

Many thanks to Dr. Steven J. Burian, Professor Stephan J. Nix, Dr. Robert E. Pitt and Dr. S. Rocky Durrans whose work, Urban Waste Water Management in the United States: Past, Present and Future, provided a wealth of information for the historical portion of this article

Sources:

Abram, Susan, “More of LA County’s Homeless are Dying.  Here’s Why,” Daily News, January 17, 2018, https://www.dailynews.com/

Berezow, Alex, “Homeless Camps Are Infectious Disease Time Bombs,” September 13, 2017, https://www.acsh.org/

Blanton, Lucas S., David H. Walker, “Flea-Borne Rickettsiosis and Rickettsiae” June 30, 2016, The American Journal of Tropical Medicine and Hygiene, https://www.ncbi.nlm.nih.gov/

Burian, PhD, Steven, et al., “Urban Wastewater Management in the United States:  Past, Present and Future,” Journal of Urban Technology, 2000, PDF: http://wvwv.sewerhistory.org/

Chiland, Elijah, “LA Sanitation Needs 17M to Keep Up With Homeless Encampments,” February 22, 2018, https://la.curbed.com/

Chou, Elizabeth, et al., “LA Sanitation Crews Can’t Keep Up With Rising Homeless Camp Cleanups, Seek to Double Their Ranks,” Daily News, February 21, 2018, https://www.dailynews.com/

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