By the time friends decided to call Darcy Burrows an ambulance, she was too weak to move.
At the hospital, doctors told the 41-year-old San Diego homeless mother of two that she had hepatitis A. Mystified, she asked how she contracted it. "They said: 'Haven't you been watching the news?'"
In North America, most outbreaks of hepatitis A – which is caused by people ingesting even tiny amounts of infected feces – have been traced back to food, often passed on by infected farm and food-service workers, or through uncooked fish taken from polluted waterways. But in San Diego, hepatitis A has spread quickly among the growing homeless population living in crowded makeshift encampments along riverbanks and in downtown parks, where they have little access to bathrooms and showers, and where people frequently share food and drinks.
Police encourage homeless man Stephen Schofield to get a hepatitis A vaccination near where Mr. Schofield is living along the San Diego River in San Diego. A recent hepatitis A outbreak reflects how much homelessness has become a crisis in San Diego.
People such as Ms. Burrows, an alcoholic whose life spiralled out of control after her youngest son died of a rare brain disorder four years ago, are at the epicentre of the deadly outbreak that has swept through the city and several others in the U.S. The outbreak, which started a year ago and peaked in late fall, has killed 20 people and sickened nearly 600 in San Diego, making it the largest since the U.S. introduced a vaccine more than 20 years ago.
The spread of the disease has been concentrated among the homeless and illicit drug users, who are also often exposed to unsanitary conditions. But about a third of those infected and two who died were neither homeless nor drug users. (Experts don't know exactly how the disease spread to the general population, but it is easily transferable by even the slightest contact with infected feces.)
That has helped spark a public outcry in San Diego to address the city's long-standing issues with homelessness. It has also pushed the deadly epidemic into the international spotlight as a cautionary tale of how ignoring an affordable housing crisis can have broader public health consequences for cities – including those in Canada.
"We shouldn't be surprised from a public health perspective that an illness like hepatitis A is so prevalent because we take vulnerable people, we isolate them, put them at risk and we deprive them of the reasonable health services," said Dr. Jeff Turnbull, chief of staff of the Ottawa Hospital and a globally recognized expert on providing health care services to the homeless. "Any public health official would say that is absolutely a recipe for an outbreak."
Jose Salinas sprays a bleach solution on a downtown San Diego street as part of the city’s efforts to combat the recent hepatitis A outbreak, which has been tied to fecal contamination.
While Canada has yet to see a large outbreak of hepatitis A among its homeless, diseases such as tuberculosis and H1N1 have similarly spread quickly in overcrowded shelters and later crossed into the general population, Dr. Turnbull said.
There are several theories about how San Diego became ground zero for the outbreak, including the city's decision to relocate homeless people into crowded parks to make way for the 2016 Major League Baseball All-Star Game, and a California ballot measure to ban plastic grocery bags, which some homeless residents had used for toilet purposes.
But many here see the city's affordable housing crisis as the overarching cause. Average rents in the city have soared more than 20 per cent in the past three years to nearly $2,500 (U.S.), and officials estimate the city has lost 10,000 affordable housing units in the past six years as cheaper apartments were turned into luxury housing. San Diego has the fourth-largest homeless population in the United States, with more than 5,600 people living on the streets this year, a 40 per cent increase over three years.
Meanwhile, the city has been slow to add facilities, such as public bathrooms in areas where the homeless congregate. Despite warnings from a local government watchdog, San Diego has closed more 24-hour public bathrooms in the past few years than it has built in the city centre, usually because of concerns over safety and cost.
In a downtown park popular with the city's homeless, Mike Smith points to a public bathroom attached to a restaurant that had been closed on and off for more than a year. "If people don't want to see this [outbreak] duplicated in their community, then go about things intelligently," said Mr. Smith, 58, who has been homeless for two years and was also recovering from hepatitis A. "Human beings defecate. Provide them with a place to do it and a place to wash their hands when they're done."
The San Diego epidemic was exacerbated by the fact that most homeless people don't have a regular family doctor who knows their health history. Instead, they often go to emergency rooms where doctors usually focus on treating short-term issues, and may not notice the significance of a handful of patients testing positive for the disease. That made it difficult for public health officials to spot the outbreak early on, and to track down people who needed to be vaccinated, said Dr. Robert Schooley, head of infectious diseases in the medical school at University of California, San Diego.
Since San Diego's outbreak began drawing national attention in the summer, the city has washed downtown streets with bleach, installed automatic public toilets and hand-washing locations, and given out more than 100,000 vaccines. This month, it opened three large tents on city-owned land to house 700 homeless residents. The structures include garbage facilities, bathrooms, showers and hand-washing stations.
Christine Wade, left, sorts clothing in the family’s tent provided by the city in a sanctioned encampment in San Diego in October, 2017. The Wade family is among several hundred people living in the city’s first campground open for the homeless, set up to curb the hepatitis A outbreak.
But critics argue the tents are expensive temporary solutions at a time when the city should be focusing on getting more of its homeless into permanent housing. San Diego has opened similar tents in the past, but closed them down two years ago to funnel money into housing plans. This year, it took millions from an affordable housing program to reopen the tents.
"This is the easy thing to do to say the problem doesn't really exist, because nobody can really see it any more," said San Diego city councillor David Alvarez. "But we all know it's still there and it's going to get worse, because we've done it before and it's only gotten worse over the years."
Dr. Schooley worries the public attention on the housing crisis may prove to be short lived, setting cities like San Diego up for another outbreak. "Ignoring vulnerable populations like this does make communities at risk for much bigger costs down the road that people don't think about, don't talk about and don't want to address," he said.
Ms. Burrows is a case in point. She spent two months in hospital and another two months recovering in a rehabilitation centre battling hepatitis A and other complications from the disease. When she was well enough to be discharged, social workers took her right back to the street.
She has put her name on several waiting lists for social housing and for a spot in the emergency tents, to no avail. So she lives in a tent on the outskirts of the same park where she first got sick. "You would think will all the health problems that I have that I would be able to find something," she says. "I'll go anywhere right now."