Going viral: If Hepatitis A outbreak reaches Sacramento, politicians could have themselves to blame

Sacramento ignored warnings from former public health officer, United Nations envoy on the path to health scare

Karen Leland is the safety and security coordinator for the Sacramento Public Library, which is one of the last places in town homeless people are welcome to use the restrooms.

Karen Leland is the safety and security coordinator for the Sacramento Public Library, which is one of the last places in town homeless people are welcome to use the restrooms.

Photo by Raheem F. Hosseini

This is an extended version of a story that appeared in the October 5, 2017, issue.

Marcy sat on a blanket in the shade of the new Cesar Chavez Plaza, with its polished courtyard, city-subsidized restaurant and the bathrooms she’s not allowed to use. Beside her stood a two-wheeled cart stocked with possessions and sundries, including two dwindling rolls of toilet paper. She doesn’t need to use the restroom now, but when she does, she knows it will be an ordeal.

“It sucks, especially if you’re homeless,” Marcy said.

Marcy is homeless. She has been for two years, she says. When nature calls, her options are few and measured in city blocks.

“I go to the library. I go to City Hall. Sometimes, if it’s really, really late at night and Amtrak’s closed, I go all the way to the Hyatt,” she explained. “And then, they give you that look, like, ’Oh my God, watch her, she’s doing something.’”

This is the reality for thousands of people experiencing homelessness in Sacramento County. Public restroom access isn’t usually treated like a topic of pressing importance, but it’s playing a starring role in a Hepatitis A outbreak that’s crawling up California, leaving hundreds sickened and more than a dozen people dead from a virus that thrives in human excrement and hops from person to person through the consumption of contaminated food or water.

If the liver-compromising virus breaks out here in Sacramento, local officials will be able to count several years’ worth of ignored warnings among their missed opportunities to prevent the preventable. They’ll also be in the company of public servants from throughout the state, who resisted calls to make clean water and public restrooms available as homelessness exploded in their communities.

“Now we’re getting more complaints about public defecation and the Hepatitis A scandal,” said Councilman Jeff Harris, who has been trying for months to get portable bathroom facilities online in the city. “We call ourself a full-service city? We’re missing the mark.”

The outbreak started in San Diego County, where officials watched as a virus that typically infects two to three people per month ballooned to more than 400 cases since November—16 of which proved fatal. Santa Cruz was the next to sound the alarm, with 68 confirmed cases in a county that typically sees two to three cases per year. And on September 19, Los Angeles became the third county to declare an outbreak, with six out of eight Hepatitis A patients hospitalized.

Perhaps most unsettling for Sacramento County is the population amongst which the disease is spreading most quickly in the three infected counties: unsheltered homeless men and women, a group found by an overnight census to have more than doubled in Sacramento since 2015.

Before the outbreak, though, Hepatitis A was already rising in Sacramento, according to local data.

There were 12 confirmed cases of Hepatitis A last year, quadruple the number of people who fell ill with the disease in each of the previous two years, according to a fact sheet provided by Health and Human Services spokeswoman Samantha Mott. Those high numbers are continuing through 2017. Mott told SN&R there have been seven confirmed cases of Hepatitis A in Sacramento County this year, with one more under investigation.

Mott said none of the cases have been linked to the outbreak in SoCal. But the conditions that made them possible are similar.

San Diego finds itself at ground zero of a statewide outbreak, which health officials have attributed directly to the city’s lack of public restrooms downtown. Similarly, Sacramento’s record of intransigence reaches back more than a decade.

In 2005, every city in the county except Sacramento refused to legalize clean needle exchanges at the urging of the county health officer, who was trying to contain a tuberculosis outbreak. Even the county turned her down.

In 2012, a special envoy with the United Nations publicly condemned the city of Sacramento for not providing clean water and public restrooms to homeless residents. In the years since, public restrooms and working drinking fountains have declined further.

The city did experiment with making portable restrooms available in the River District under the watch of paid monitors last year, but pulled the plug due to cost overruns.

And this year, the Sacramento City Council rejected one of its members’ plans to establish a dormitory-style encampment in his district, where homeless people could access, among other things, restrooms and showers.

Those working with the homeless community are drawing a direct line between the political inaction and health dangers.

“This Hep A outbreak is the consequence of our inability to provide a solution to solve that problem—homeless individuals not having access to restrooms,” said Melinda Ruger, executive director of Harm Reduction Services in Oak Park, which treats addiction in the homeless and sex-worker communities.

Dr. Ted Zwerdling, the chief medical officer of Elica Health Centers in Sacramento, stressed that Hepatitis A is most common in people who have not been vaccinated against the virus and people with extremely compromised immune systems, such as AIDS.

“I wouldn’t downplay sanitation,” Zwerdling added. “If you’re not immunized, that’s how you can get it.”

A Sacramento County public health announcement says that Hepatitis A is transmitted person-to-person, and occurs most frequently from illicit drug use, needle sharing and unsanitary living conditions. According to the fact sheet provided by Mott, Sacramento County experienced a 71 percent increase in Hepatitis A cases between 2012 and 2016. That partially coincides with flattened immunization rates in California kindergarten classes, which have rebounded since a new state law went into effect last year.

Mott said officials are working directly with the California Department of Public Health to develop a preventative action plan.

Dr. Olivia Kasirye, the county’s public health officer, told SN&R that the response will happen in phases, with immunization clinics scheduled both inside temporary homeless shelters and out in the field where homeless people congregate.

Not everybody, however, is sold on the county’s response.

Civil rights attorney Mark Merin argues that by the time vaccinations are being offered to halt an outbreak, it’s too late. “If it’s being spread by shared needles, provide clean needles. If it’s being spread because people are having to defecate outside, then provide bathroom access,” he said. “True prevention must be systemic rather than reactive.”

Following an SN&R cover story on the lack of accessible facilities in Sacramento County (read “Right to relief” by Raheem F. Hosseini, Feature, April 21, 2016), the city of Sacramento agreed to test out a portable rig containing three restrooms, monitored by paid attendants, in the River District. During the six-month experiment, the restrooms drew more than 20,000 visits and resulted in the collection of over 700 needles. But the costs proved higher than expected and the pilot project was scrapped at the end of last year.

Ruger, whose nonprofit provides access to free STD testing, clean syringes, and overdose prevention and response training to homeless and sex worker populations, criticized that decision as a penny wise and a pound foolish.

“What’s a Hepatitis A outbreak going to cost?” Ruger asked rhetorically. “How much will the hospitals spend treating 400 homeless men and women from an outbreak versus how much it would have cost to provide access to restrooms to prevent the outbreak?”

On January 10, the City Council considered cheaper ways to revive monitored restrooms on an ongoing basis. Nine months later—in the midst of a major public health scare—the city is finally close to picking one of those options.

The local librarian had been threatening City Hall with Porta-Potties.

Sacramento Public Library Director Rivkah Sass and Councilman Harris can joke about the unusual ransom deal now. But for most of the year, the downtown library at I and Eighth streets has offered “the last free, open and public” bathroom in the city, Sass said.

“We feel our commitment,” Sass told SN&R. “We really care about our unsheltered folks.”

At the same time, carrying that burden by its lonesome was taxing for the central library, which pays power-washing and maintenance costs out of its humble budget. Harris says—and Sass confirms—that the local librarian was considering taking matters into her own hands.

“She marched up here and said, ’Damn it, I’m gonna put Porta-Potties on the street,’” Harris recalled.

Instead, the two are about to propose an arrangement that they hope will serve as a model for the rest of the city.

Harris told SN&R that he’s close to a deal with a state agency to put up half the money to pay attendants to monitor the restrooms inside the public library. As the library already makes its restrooms open to the public, the deal wouldn’t add more capacity to the central city. But it would prevent the type of restroom abuse that forces Sass to spend library resources on biohazard cleanup. And both she and Harris are hoping other public agencies—and maybe even some businesses—see it as something they’re willing to partner on.

“I think the goal is to serve as an example,” Sass said. “We are all one bad decision from where they are. There but for the grace of God go I, in my opinion. I think about that all the time.”

Harris is still hoping to bring modular restrooms back in a cheaper fashion. He says retrofitting one of the restrooms to be compliant with the Americans with Disabilities Act proved to be the financial undoing of the pilot project, and is hoping the unique arrangement to staff “as-built” restrooms that are already ADA-compliant with paid monitors might be an acceptable work-around to that requirement.

Based on how popular the River District portables proved, he knows there’s an audience for them. “Twenty-five thousand uses is extraordinary. In the ensuing six months, those 25,000 uses have been in the streets,” he said. “Think about that.”

Sass is happy that action is finally being taken. She knows her library’s partnership with the city won’t add new pieces to the game board, but she hopes it will inspire others to open their restrooms. Sass, whose roots are as a children’s librarian, offers one of her favorite quotes:

“How do you eat an elephant?” she asked. “One bite at a time.”

Back at Cesar Chavez Plaza, Marcy says she and her partner used to live near the river, where other homeless people set up camps in an attempt to avoid detection by authorities enforcing laws against sleeping outside. As area politicians began locking public restrooms in parks and trails in response to vandalism and rising maintenance costs, more people began defecating wherever they could find a little bit of privacy. And sometimes not even that.

Marcy left the riverbanks, not because of the human waste, but because she got tired of her stuff being stolen. This was during the recent summer, the hottest on record. Because she has two dogs and doesn’t like being around other people, she didn’t make it to one of the cooling shelters. Neither did her partner.

“He died of a heat stroke,” Marcy said. “He collapsed out in the river.”

She didn’t find out until it was too late to do anything. She sets her jaw and diverts her eyes.

“We were going to get married,” she said. “His name was Marvin Shepard.”