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'If Not Us, Who?': Dr. Drew Urges Clinicians to Speak Up on West Coast Infectious Disease Crisis

JUN 17, 2019 | ALEXANDRA WARD
Drew Pinsky, MD, is calling on his peers in medicine to help sound the alarm about the abysmal conditions on the Pacific Coast driving the explosion of infectious diseases that have some cities, particularly Los Angeles, teetering on the brink of a humanitarian crisis.

“Speak up and talk about what you’re seeing in the emergency rooms and in the clinics. We are the early detection systems. We know what’s going on before anybody. We see the trends, we know what they are, we see it coming,” Pinsky, an internist and globally recognized addiction medicine specialist, told Contagion® in an exclusive interview.

The problem stems from the homeless population, Pinsky said, and the “gigantic unsanitary accumulations” that go hand-in-hand with thousands of people living on the streets.

“It is an absolute complete breakdown where the people living on the streets are defecating and urinating and every excrement, every byproduct of what they’re eating and food and everything else is just piling in the streets,” he explained.

The number of people experiencing homelessness in Los Angeles County rose 12% this year, and increased 16% within the city itself, according to newly released statistics from the Los Angeles Homeless Services Authority.

The uptick in the rate of people without permanent housing, coupled with a dip in the vaccination rate and a rise in medical exemptions to vaccines, has created a trifecta of opportunity for infectious disease that has health experts worried about a potential pandemic. Factor in the crumbling sanitation infrastructure and there are all the makings of a serious public health emergency.

Among large homeless populations “there is…an increased risk for communicable or infectious diseases, such as hepatitis A, associated with a lack of proper sanitation (especially the lack of hand-washing, bathing, and clothes-washing facilities) as well as for those associated with rodent infestations and the insect vectors they can carry,” a spokesperson with the Los Angeles County Department of Public Health told Contagion®.

The trash, combined with the human waste generated by the city’s 36,300 homeless individuals, has led to a resurgence of some diseases not seen since the Middle Ages— typhus and typhoid fever, to name a few.

From January 1, 2018, through June 1, 2019, there have been 111 confirmed cases of human flea-borne typhus in California, according to the state Department of Public Health. That’s up from just 13 cases in 2008. Just last month, an LAPD officer was diagnosed with typhoid fever while a couple other LAPD staff reportedly displayed symptoms.

“Now we have tuberculosis, measles, typhus…I started looking at what usually comes on the heels of typhus in this area, and that’s Yersinia (bubonic plague),” Pinsky told Contagion®. “It has been documented on the squirrels, and it’s just a matter of time before it gets on the rats, then our pets, and then on us.”

“I really dread what’s coming this year. We have essentially every means of transmission of infectious diseases represented in these outbreaks,” he continued. “We have oral-fecal with the typhoid. We have airborne with the tuberculosis and measles. We have rodent-vector with the typhus and the Yersinia. So here we go. Every major means and component of severe dangerous epidemic infectious disease are set up to go and nothing is being done.”

According to LA Public Health, the increasing cost of housing and the need for community-based support services for individuals with mental illness and/or substance abuse disorders are 2 factors contributing to the rise in the number of people experiencing homelessness.

Pinsky agrees that services for the mentally ill must be strengthened, but also urges the health care community to take action.

“People say it’s complex; I think it’s simple. First thing, I would go out and vaccinate all the homeless with MMR. My second move would be to go to the state legislature, which I’ve already done, and change the Lanterman-Petris Act,” he said. “We have to change the criteria for greatly disabled. In the 1960s, it changed from ‘need for treatment’ to ‘harm to self or others’ and that’s a giant gap. We have to have things like ‘unable to care for medical needs.’ We have to be able to help people and protect their wellness.”

LA Public Health does provide immunizations at encampments and is working with local governments to improve living conditions for individuals experiencing homelessness, an agency spokesperson said.

The agency also identified 4 areas where improvements can be made to address the spread of disease among those experiencing homelessness: Housing—Get and keep people housed in affordable, habitable and stable housing; Hygiene—Ensure easy access to facilities for personal hygiene (hand washing with soap and clean water) and sanitation (proper waste disposal); Health care, including immunizations—Immunizations are a cornerstone of public health prevention, in addition to access to health care for diagnosis and treatment of disease to control its spread; and healthy environments—Prevent illegal trash dumping and ensure frequent trash cleanup and effective rodent control at and around encampment sites.

But it’s not just the high rate of homelessness that is driving the surge in infectious diseases in LA. The issue is much more complex, likely attributable to a confluence of societal, environmental, political, and socioeconomic factors.

For example, Los Angeles lacks a rodent control program, Pinsky pointed out. Also, as a sanctuary city, there is a high volume of illegal immigration, which triggers fears of imported illnesses and parasites. The sanitation systems are also crumbling, and a decline in vaccination rates means small pockets of unvaccinated individuals are growing.

California falls below the US Centers for Disease Control and Prevention’s recommended 95% vaccination rate, which is believed to be necessary to retain herd immunity. The state did away with personal belief exemptions in 2015 but, since then, permanent medical exemptions have begun to creep up, from 0.7% to 0.9% over the past year, according to a recent report by the California Department of Public Health’s Immunization Branch.

SB 276, a bill aimed at strengthening the criteria for medical vaccination exemptions, is backed by the California branch of the American Academy of Pediatrics and the California Medical Association, and recently passed through the California Senate. It will soon move on to the State Assembly.

But, for now, it is up to health care practitioners to hold the megaphone and sound the alarm.

“I personally feel like I’m standing on the railroad tracks waving at a train trying to tell him the bridge is out and getting flipped off by the engineer,” Pinsky said. “I’m encouraging you to stand on the tracks and wave if these things start happening in your community. If not us, who?”

Read Dr. Drew's full interview with Contagion® here
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