Ed Blitz started feeling exhausted in mid-June.
Blitz is a fit, 71-year-old retired CPA, who lives in Bankers Hill. One day, he uncharacteristically lagged behind his wife Sue on a hike. Then he lost his appetite. Two weeks later, his eyes and skin turned yellow.
The couple rushed to urgent care. The diagnosis shocked them: Blitz had hepatitis A.
Doctors told Blitz there was no treatment for him. All they could do was weekly blood tests, a liver scan and regular check ins.
A county epidemiologist called to interview him. They discussed whether he may have picked up the virus during a recent trip to New York or from a meal out. County epidemiologists later confirmed Blitz’s case was linked with the outbreak spreading throughout San Diego.
He’s one of more than 100 San Diegans who aren’t homeless or illicit drug users who got sick with hepatitis A. The call from the county, though, was the first he had heard of an outbreak.
By June, however, the crisis was already three months old.
Major efforts to alert others of the risk were still months away.
When county health officials quietly declared the outbreak in a March email alert to health and public safety officials throughout the county, it didn’t draw much attention.
Hepatitis A, typically a food-borne illness, has become far less common and deadly since a standard vaccine was introduced years ago. In 2015, the Centers for Disease Control and Prevention tracked less than 1,400 cases nationwide.
The virus spreads when a person ingests trace amounts of fecal matter from a person who’s infected with it.
County officials’ initial alert reporting 19 cases – just over double what they’d normally expect over the previous four months – didn’t inspire urgency or even attention from most local government officials.
Public health officials linked the outbreak to drug users and homeless people or those who interact with them, not the general population. The county contacted homeless service and substance abuse providers and other government agencies to offer informational presentations and vaccines.
The county also suggested nonprofit staffers who work with those groups get vaccines too.
Most city of San Diego officials were unaware of the outbreak at that time. Those who were didn’t go on high alert.
Stacie Spector, then Mayor Kevin Faulconer’s point person on homelessness, said she contacted city shelters to ensure they were taking precautions.
“The situation in March did not merit panic,” Spector said.
Then the cases started picking up.
By mid-April, 42 people had been hospitalized, and two had died.
At that point, some city officials started to show more interest. Emails obtained by Voice of San Diego through public records requests show sporadic discussions on the topic, mostly with a cordial, matter-of-fact tone.
For example, a county official emailed Assistant Chief Operating Officer Stacey LoMedico to see if she could help circulate a flier encouraging at-risk San Diegans to get a hepatitis A vaccine.
By early May, the situation worsened. Three patients were dead, and there were 80 documented cases.
County and city officials sat down for their first face-to-face meeting on May 4.
Earlier that day, Spector said, Chief Operating Officer Scott Chadwick gathered city department directors to brief them on the outbreak and a plan to ramp up work with the county.
Spector said that there seemed to be clear direction: “The city would be working in partnership with the county. The county was the lead.”
In interviews, city officials made that point repeatedly: Per state law, the county leads on public health efforts in the region, so the city was counting on county officials to tell them what to do to respond to the outbreak.
Concern Ramps Up
Through May, the county focused intensely on vaccinations. Health officials insisted vaccinations were the most powerful tool against hepatitis A.
But county officials realized they had a more challenging outbreak on their hands.
“In the May timeframe, we were thinking that this was something that was continuing to increase and was not decreasing right away,” said Dr. Eric McDonald, a former Navy doctor who leads the county’s epidemiology team. “I think that was an early signal that this had the potential for becoming what we now can say is a unique outbreak.”
County bureaucrats decided they needed to bolster their approach. Rather than expect homeless San Diegans to come to them, they’d need to go to their encampments. They began teaming county nurses with homeless outreach teams, offering thousands of vaccines. They also inked deals with 20 hospital emergency rooms and clinics to have them inoculate at-risk patients.
That wasn’t a foolproof process either. Many homeless San Diegans were resistant. Some weren’t aware of the outbreak. County teams and service providers handed out hygiene kits on their outings. They also tried to emphasize the importance of hand-washing and hygiene, two tools crucial in the fight against the virus, to a population lacking easy and consistent access to restrooms and thus the ability to follow through.
Broader discussions about how to increase access to those amenities would only come months – and several deaths – later. A county spokesman said this week that public health officials began broaching conversations about those needs behind the scenes in May, only to be initially rebuffed by the city, the Union-Tribune reported. City officials say otherwise.
The epidemic continued to grow. By the end of May, there were more than 130 cases; by mid-June, there were 160. The death toll hit four.
That’s when Blitz got the infection. He suspects he might have contracted it during one of his regular morning visits to Balboa Park.
After his diagnosis, Blitz spent weeks on the couch. At one point, Blitz was so restless, he asked his wife if he could help with chores. He had to sit down after dusting just a few items.
“I just couldn’t do anything,” Blitz said.
City Councilwoman Lorie Zapf has long volunteered on San Diego River clean-ups.
But she didn’t think about the connection with hepatitis A until a June gathering in Pacific Beach where someone mentioned efforts to feed homeless people living along the riverbed. Zapf pictured the homeless camps, trash and feces she’s seen during past clean-ups and police ride-alongs.
Could hepatitis A spread from the hundreds of homeless people living along the river and to others who spend time along the riverbed and at beaches? Should the city be concerned?
“I thought, ‘I wonder if they’re doing all the proper cleaning,’” Zapf said.
Over the next few weeks, Zapf’s tried communicating with county officials about her concerns. She could not get answers.
On July 14, she sent a letter to Supervisor Ron Roberts with seven questions about potential river contamination and the risk of spread of hepatitis A.
“Our river valley is environmentally sensitive lands (sic) and feeds into the Pacific Ocean,” Zapf wrote. “I am concerned about the spread of hepatitis A to the population living along the river as well as those who recreate at the end of the river.”
She waited nearly two weeks for a response.
County and city officials, including Zapf, weren’t sharing these concerns publicly. News stories on the outbreak garnered little attention from most city or county leaders.
Behind-the-scenes conversations may explain why.
Faulconer had not mobilized. Aimee Faucett, his chief of staff, said city officials came away from discussions with the county thinking that the outbreak would peak and level off sometime over the summer. They trusted county officials’ assurances that a vaccination-focused strategy would stem the outbreak.
“They were anticipating that at some point, if you vaccinate the certain affected population, that you will see the outbreak slow down and start to get under control,” Faucett said.
But LoMedico, the city’s chief liaison with the county, couldn’t confirm that had been the message and Faucett, who began working for Faulconer in mid-July, couldn’t say when that message was communicated.
A county spokesman said Faucett’s claim was inaccurate.
“Public health officials have consistently stated that we cannot predict how long the outbreak would last as this was an outbreak of unprecedented proportion, unlike any other that we have seen,” county spokesman Mike Workman wrote in a statement.
Regardless of what actually happened, this much is certain: The outbreak wasn’t slowing.
Emails obtained by VOSD show city and county officials discussed new tacks to fight the virus in late June: a broader ad campaign to increase public awareness, and a pilot program to put hand-washing stations in areas where homeless people gather.
Then weeks passed.
‘I Probably Would Have Died on the Street’
Word of the outbreak started to spread on the streets as more nurses and outreach workers visited homeless camps.
Danielle, a 33-year-old staying near Fault Line Park in East Village, had heard about the virus. Danielle and her boyfriend had even gotten the vaccine at a nurse’s urging.
So they initially thought they were simply under the weather when their health started to worsen.
Danielle, who struggles with alcoholism and asked that I not publish her last name to protect her privacy, had ended up homeless about a year earlier after moving to San Diego for a rehab program only to learn there wasn’t an open slot for her. She often shared bottles with friends, a move she now believes may be the culprit behind what would become a near-death experience.
First, Danielle recalls sleeping all day for two or three days straight. Then she lost her appetite.
She got so bloated, she felt like she’d eaten two back-to-back Thanksgiving dinners.
Danielle’s boyfriend Robbie Harn, 30, wasn’t feeling well either. At some point, his eyes turned yellow.
One miserable night, sleeping outside an East Village church, Danielle decided she’d call 911 the next morning.
When the couple got to the hospital, both learned they were in fragile condition.
Danielle said doctors drained almost a liter of fluid from her abdomen. Fearful family members rushed to San Diego. Danielle, who remembers nothing of her initial days in the hospital, learned they had visited after they’d left.
“If I hadn’t called (911) that day, I probably would have died on the street,” Danielle said.
Answers Come Slowly
Throughout July, the county was continuing to try to primarily combat hepatitis A with vaccinations. Health workers across the county had vaccinated about 12,000 people, including thousands considered most at risk.
But public awareness campaigns and other efforts were barely inching forward.
On July 13, two hand-washing stations went up outside a quiet county health complex in Midway, miles from downtown streets considered ground zero of the outbreak.
County health officials said they believed poor hygiene fueled the spread of the virus, yet efforts to deploy more hand-washing stations stalled for weeks.
In interviews last month, county officials said bureaucratic red tape, an issue with a vendor and an inability to swiftly coordinate with city officials kept them from deploying stations more quickly.
And they insisted that the plan to put out hand-washing stations needed to start with a pilot program rather than be rolled out on a larger scale – even as the outbreak and deaths tied to it escalated.
In a statement this week, a county spokesman said it was the city that suggested beginning the pilot on county properties – rather than in the heart of downtown – and that at one point, the city rejected the county’s offers to pay for handwashing stations within the city.
Emails show that in initial conversations, county health officials described only a small pilot program for hand-washing stations, not a broader plan.
At the end of July, LoMedico emailed a county public health official about posters a second time, a month after an initial exchange about fliers for city libraries and rec centers. They wouldn’t be printed for another three weeks.
Zapf had been waiting too.
Dr. Wilma Wooten, the county’s public health officer, responded nearly two weeks after Zapf’s letter to Roberts inquiring about the risk of hepatitis A spreading through contaminated San Diego River water.
Wooten wrote that county Health and Human Services Agency officials had linked four cases, including one death, to the river valley area, though it was unclear whether they’d contracted the virus there.
She also noted that hepatitis A can persist in a river bed for “days to months” depending on the conditions. The risk of spread was unknown but expected to be “very low.”
“Any material that is contaminated with hepatitis A virus, including human feces, that enters the San Diego River could potentially be transmitted downriver, though significant dilution would occur in transit,” Wooten wrote.
Then came the kicker that rattled Zapf: “Our county team welcomes any of your suggestions and recommended partnerships to help protect the river valley and unsheltered individuals, seeking refuge in the area, the services they need.”
Zapf was shocked by the response – and its lack of urgency.
At the time, the memo was labeled confidential.
Donna Cleary, a Zapf staffer who’s led discussions with the county about hepatitis A, emailed Roberts’ chief of staff to ask if he would be interested in teaming on a clean-up effort.
“This would be a multi-jurisdiction and multi-agency type of cleanup that potentially would save lives and restore sensitive habitat to a better condition,” Cleary wrote in an Aug. 2 email.
Sal Giametta, Roberts’ chief of staff, replied within an hour.
“Let us give the suggestion some thought,” Giametta wrote. “Will be back to you before long.”
Cleary and Zapf say they waited for weeks for more clarity on whether county officials might help with a clean-up.
By late August, the death toll reached 15 and more than 330 people had contracted hepatitis A.
The pilot program to place hand-washing stations in places where homeless people congregate remained a pilot program with just two stations outside a county health complex.
In early August, emails show county officials mentioned a plan to install a single additional downtown hand-washing station outside a busy downtown county welfare office. LoMedico emailed officials with the city and county to share details on a permit they could pursue.
Soon after, the county told LoMedico they wanted to install more hand-washing stations.
At a meeting with VOSD and county officials two weeks after the email exchange about a permit, LoMedico said the city was prepared to authorize a single permit to cover any sites the county wanted to proceed with within a few days.
Dale Fleming, a director in the county’s Health and Human Services Agency, said city and county lawyers had been hashing out the wording of the permit in the two weeks since LoMedico shared information about the approval the county sought.
Around the same time, Metropolitan Transit System officials voiced concerns about a county request to place two hand-washing stations outside their East Village hub, fearing they might draw more homeless people to the area.
“My only thoughts are that this would probably become a magnet for homeless people to come onto our property just to use the sink (take a bath, brush their teeth, wash their dishes, etc.), especially during non-revenue hours,” MTS security director Manuel Guaderrama wrote in an Aug. 15 email. “Perhaps the health department can set up locations with just the sanitizer.”
By Aug. 30, just one additional hand-washing station had been placed downtown.
That same day, VOSD published a story documenting bureaucratic fumbling amid the deadly hepatitis A outbreak.
That’s when the pace of the local government response to the hepatitis A outbreak drastically shifted. Officials began scrambling.
On Aug. 31, City Councilman David Alvarez, a Faulconer critic who plans to run for county supervisor in 2020, called on the city to declare a homeless shelter crisis. (It later turned out there was already one in place.)
Wooten and county Chief Administrative Officer Helen Robbins-Meyer issued a directive to the city, demanding a plan to power-wash downtown streets and sidewalks with a bleach solution, and that it allow the county to install dozens of hand-washing stations. It also called on the city to increase access to public restrooms.
Faulconer asked county officials to consider declaring a state of emergency, a move he believed would help the city cut through red tape that might slow the city’s sanitation response and potentially bring in state or federal funds to address the outbreak.
The next day, a Friday, Robbins-Meyer declared a local health emergency and called a special Board of Supervisors meeting to ratify it the following week.
By the end of the weekend, county contractors had placed 40 hand-washing stations across the city in areas where homeless San Diegans congregate.
At a Sept. 6 meeting, county officials described the emergency declaration as a tool primarily meant to raise awareness of the hepatitis A outbreak and to ensure the county could better work with cities on sanitation improvements.
In separate statements to VOSD, County Supervisors Dianne Jacob and Greg Cox said the county had opted against such a declaration until that point because they hadn’t been assured it’d mean additional cash from the state.
“Months earlier, the county asked the state about the impact of a declaration and we learned that a declaration would not bring any more resources to the region,” Cox said.
It became clear the primary value of the declaration was the public awareness it might bring. And it did. The news media mobilized. Long lines formed at mass vaccination events and the story went national, much to the mayor’s embarrassment.
But the awareness was too late for many.
Blitz, somewhat relieved by the increased attention the outbreak was receiving, showed up to speak at the county meeting. He was feeling better.
“I am here to urge the board to take every step necessary to address this hep A crisis,” Blitz told supervisors, his voice breaking as he spoke. “I’m also here to tell you that this crisis does not only affect the homeless population.”
The board later voted unanimously to approve the declaration.
Where Was the Urgency?
Jacob, who chairs the Board of Supervisors, lauded the county’s efforts up until then, specifically the roughly 19,000 vaccinations given.
“Nineteen thousand is impressive and I think it demonstrates that where the county has had the authority to act quickly and to move on this issue, that 19,000 vaccinations demonstrate that,” Jacob said. “Where the difficulties came in is where we needed permission, in this case from the city, to do certain things.”
Some city officials viewed the situation differently.
This came to a head on the same day city contractors began power-washing city streets and sidewalks. That day, Zapf asked fellow City Council members to support including the San Diego River area in clean-up efforts.
Two days later, Zapf confronted Wooten at a public hearing. She wanted to know: Would the county help clean the riverbed?
A tense exchange followed.
After Wooten explained that the county is responsible for unincorporated areas and the city within its boundaries, Zapf interrupted: Was the city solely responsible?
Wooten again said that the city and county have different responsibilities.
Zapf was dissatisfied.
“I think the action could have come earlier and I think that, not moving backwards but moving forward, the county needs to be much more of a partner in this effort than it really has been, and it’s really critical now,” Zapf said.
The next day, Zapf and Alvarez sent a letter to the mayor, county and four other agencies with jurisdiction over the river to ask that they help expedite a clean-up of the riverbed.
The county said it’s not its responsibility to help.
Robbins-Meyer fired off a letter to Chadwick, her city counterpart, expanding on the broader directive sent on Aug. 31.
“To conform to the direction given by the county, the city must take measures to sanitize all contaminated areas where homeless reside within the city’s jurisdiction including, but not limited to, riverbeds and ravines,” Robbins-Meyer wrote.
Neither the county nor the city publicized that new information.
A mayor’s office spokesman said the city is now planning additional clean-up efforts in the next few weeks.
Both the city and the county are trying to increase public awareness of the outbreak.
They held their first press conference about their hepatitis A response on Sept. 19, more than six months after the county declared the outbreak.
There, Roberts praised the county’s response.
“The county team has earned my deepest appreciation,” Roberts said. “We have people who are working around the clock.”
Faulconer, the politician who’s taken the most flak about the outbreak, has rushed to bolster the city’s response, even in the days since the press conference.
Faucett, Faulconer’s chief of staff, largely defends the city’s response.
The mayor could have raised alarms sooner, Faucett said, but he and others city officials had thought county public officials would let them know of actions they needed to take. They didn’t get that direction until late August.
“They’re the professional health care workers, so we were relying on them and deferring to them,” Faucett said.
Workman, the county spokesman, rejected Faucett’s argument.
“There is no reason to believe city officials needed a directive from the county to inform them what steps were needed to address sanitation concerns,” Workman wrote in a statement. “City officials have been aware of sanitation problems in this community, and sanitation is the city’s responsibility.”
He said the Aug. 31 directive was issued to spur action – and it did.
Now, Faucett said, the mayor’s now spending 70 percent of his time on efforts to stem the outbreak. He’s cleared his schedule. He backed out of plans to join the Chamber of Commerce on its annual Washington D.C. trip this week.
A week after the county’s emergency declaration, the mayor announced plans to pitch three industrial-sized tents to temporarily house hundreds of homeless San Diegans. He hopes to open at least one or two by the end of the year. He’s also directed city staff to quickly add temporary restrooms downtown and to extend hours at 14 restrooms in Balboa Park.
Faulconer directed LoMedico, whose work at the city spans three decades, to focus on leading the city’s response to the outbreak. He’s also corralled another dozen city employees, led by the city’s Homeland Security chief, to coordinate and track that response. They meet at least once daily.
Other local cities have also stepped up their efforts.
El Cajon, another hub of the outbreak, began power-washing some streets last week.
The San Diego Union-Tribune reported last week that El Cajon, Chula Vista, Oceanside, National City and Escondido were all awaiting hand-washing stations from the county.
In an interview with the Union-Tribune, El Cajon Mayor Bill Wells defended the speed of the sanitation response.
“I think it was about as fast as it could have been considering this is the first time I can remember responding to a disease process like this,” Wells said. “We’ve never, as a city, had to get involved with these kinds of things before.”
But Dr. Michele Barry, director of the Center for Innovation in Global Health in the Stanford University School of Medicine, said the heightened sanitation efforts, including the hand-washing stations and restroom deployments should have come months ago, when the county began stepping up its vaccination efforts.
“If they had the resources to do that earlier, it might have made a difference,” Barry said.
Barry acknowledged lacking resources and the need to coordinate with multiple agencies can hamper public-health officials.
Coordination challenges and a lack of urgency, rather than lacking resources, seem to have punctuated San Diego’s hepatitis A response.
County officials have said their ample reserve fund can cover outbreak-related expenses. Faulconer has said the city is prepared to respond however necessary to address needs within its boundaries.
“There are lives at stake. Every person affected has a family, has friends. This is personal. This is our community and we will protect it,” Faulconer said at the press conference last week.
Dr. Nick Yphantides, the county’s chief medical officer, acknowledged at the same press conference that lives would continue to be at stake for some time.
He said the county expects the outbreak to last at least another six months.