don’t do me anywhere near as much good as words on paper (which, in today’s world translates to words in an electronic document). I have come to acknowledge that putting off finishing the requirements for the two outstanding incompletes from grad school is not doing me any good. In fact, it more resembles the garbage left too long under the sink. The longer it sits, the more it smells. The more it smells, the less you want to deal with it. At some point, the nose is held (clothespin optional) and the stinking container is emptied, washed, and put back with all good intentions to avoid this cycle in the future.

Then the future rolls around again.

Please understand – I don’t give a flip about grades, all I want it is “met enough work to warrant a pass.” Having said that – it is hard to imagine putting in hours of work researching and writing for no good reason if the end results could possibly be of benefit.

It is the old Tikkun olam. Build the world a better place.

So… the background to today’s public health challenges include the following:

1. San Francisco is an extremely expensive place to live
2. The tech boom has resulted in an increase of 100k jobs over the last decade and the loss of 30k in housing in just the last few years
3. The weather in California is not as bad as many of the other parts of the country
4. changing demographics have resulted in marginalization of portions of the population.
5. San Francisco became the mecca for a number of lifestyles starting in the 1960s

Now, back tracking to 2008-2009, there were several medical publications that discussed Hepatitis A infections and risks in homeless populations. Those discussions centered, of course due to the standard medical tunnel visions, on immunizing everyone to avoid disease.

So why was everyone in both city governments and public health circles so stunned when an epidemic of Hepatitis A started sweeping through homeless & IV drug user communities (and yes, there can be an overlap between the two). I fail to understand why anyone was surprised. Or, even more stunned to be in a situation where a normally mild disease most often seen in childhood in most of the developing world, various institutions was causing hospitalizations and death. This epidemic was recognized, not because of the obvious failure of the city, the infrastructure and public health to recognize the failure to provide for a vulnerable population but that hospitalization costs were skyrocketing.

The solution? According to the CDC – we should adopt the 2009 recommendations (hello, this is now 2017….) to add homelessness, IV drug use or MSM* to the list of peoples needing HepA immunization.

For those of you who don’t remember the history of Hepatitis A – this was the food/water borne version of hepatitis for which you (as a citizen of a developed country) received a large shot of gamma globulin in a major muscle group (usually gluteus maximus). 5cc is a significant volume, trust me. In 1995, the first versions of HepA vaccine became available. Every military member with a brain in his/her head was more than willing to get immunized. One shot with maybe a booster vs large/painful shot every 3-6 months while deployed? Other than the military, most of the other developed world citizens at risk of HepA were tourists indulging in street food while visiting developing countries. With the usual transmission being the fecal-oral route, it was obvious to everyone concerned that sanitation was as important to breaking the infection cycle as immunization.

We seem to have forgotten that bit of intelligence. It doesn’t matter if you immunize the whole world against a disease. That is one disease. As anyone who has every had noro-virus, salmonella food poisoning or one of the hundreds of other possibilities, the key to not getting diarrheal disease is availability of toilet facilities accompanied by strict adherence to hand washing. Which takes us to a city where there are no 24 hour public toilets, hand washing facilities are limited, no one wants homeless encampments, there is not enough shelter space for those who need it, and serious money is spent on a daily basis on power washing human excrement off the sidewalks.

Yes, we can immunize everyone. But it is not going to solve the sanitation issue.

I am making some basic assumptions. The first is that most people do not chose to be homeless. That they don’t set out to be vulnerable, dirty, and hungry. That, if they had the money to have food and shelter, they would. But San Francisco has teachers in their schools living in cars because they can’t afford a place to live.  I also make the assumption that mental health, substance abuse issues, and physical health issues impact lives to the point where many become homeless. And those problems don’t become better by being without a home.

<two hour break in which I spent digging through PubMed. Surprise, surprise, all the public health people, when discussing issues related to the HepA outbreak mentioned and repeatedly mentioned that sanitation was a serious issue and one of the most difficult to resolve. Having said that – it is no where in any of the CDC guidance. Just immunizations. Go figure>

I finished off the draft memo – sent it on its way, and spent sometime working on a Hitchhiker variation in a lovely yarn color called – magic unicorn.

*MSM= men who have sex with men…