To battle an outbreak, officials in San Diego have had to rethink the way they provide housing for the homeless.

When the first patients arrived at Dr. Jeffrey Norris' clinic, they had no idea they were sick. The staff found them sitting in the waiting room, exhausted and queasy—skin a sickly yellow, lids drooping over jaundiced eyes.

They came in off the streets for walk-in appointments, battling nausea in the downtown San Diego clinic, at a time when they'd normally be waiting in line for a shelter bed. Many had been treated here before for chronic conditions like diabetes, hypertension, or alcoholism. Today, they rattle off a list of complaints: fatigue, vomiting, diarrhea. Normally these symptoms would not cause concern in the clinic, which serves the nation's fourth largest homeless community, but those eyes—the whites yellowing like old wallpaper—were definitely alarming.

Norris says his staff noticed the symptoms immediately and came to him, saying, "Something's off here."

Today, news of the hepatitis A outbreak targeting California's homeless is inescapable in San Diego—pamphlets and fliers besiege the city, nurses make vaccination runs, homeless camps have disbanded and re-formed around hand-washing stations—but back in June, Norris says it took the community by surprise, especially because the United States has not had an outbreak of this kind in 20 years.

Still, Norris knew hepatitis A when he saw it. The liver disease causes fever, fatigue, and vomiting, but it's not usually fatal. Tests soon confirmed their suspicions. Out of the thousands of chronically homeless Californians that seek treatment at Father Joe's Villages, which runs the largest homeless shelter in San Diego, the clinic treated 11 people with hepatitis A and diagnosed nine by press time—just a few among hundreds who have contracted this disease state-wide.

As Norris broke the news, the patients would sit there, slowly absorbing information about the virus that had resurfaced to kill 20 people on the streets of San Diego. Most were calm, but curious. Several patients asked Norris, bewildered: "But how did I get this? Who gave this to me?" They would learn that hepatitis A spreads person-to-person, from feces to mouth, and can be prevented with a vaccine, and, more simply, proper hygiene. They would learn that risk factors include drug use and underlying liver disease—both of which disproportionally affect homeless people.

After this discussion, patients would often walk over to the hand sanitizer and take a generous amount, already eager to wash their hands of this disease. (Norris notes that, unlike soap and water, alcohol-based hand sanitizer does not actually protect people from the virus.)

Although better hygiene can help avoid outbreaks like this one, the conditions that spawned it were years in the making—and they won't be fixed with hand washing alone. With thousands crowded into unsanitary downtown encampments without access to water, San Diego's latest medical crisis is really a housing one. Norris' patients were referred to shelter facilities, where staff could keep an eye on them, but most had nowhere to go.

Before checkout, clinic staff assured the patients they would do all they could to find them a bed. But the city's shelters have waitlists ranging from two days to a month, and, at the outbreak's start, not even hepatitis A could swing someone a spot. So Norris' patients went back to the streets that had sickened them, sleeping on the pavement around East Village, making daily trips to the clinic, and washing up in public restrooms.

After a week, Norris says, their symptoms almost always improved. Their living situation did not.

Just over a mile from the clinic, homeless Californians settle into rows of red-and-gray uniform tents on an abandoned asphalt lot. The spot is more secluded than the sidewalk, and though a 24-hour security guard patrols its borders, police do not sweep this encampment. On any autumn night, about 180 people crowd into the public works yard. Families, recovering addicts, elderly folks with canes wrap up in sleeping bags—donated new—in their individual stalls, each the size of a parking spot and marked with a number. And in the corner: portable toilets and showers.

This fall, while the county vaccinated people in droves, city officials worked desperately to secure temporary housing. In October, they opened the city's first legal homeless camp for 200 people on city land, with three larger tents to follow.

Critics say the tents can hardly accommodate San Diego's 9,000 homeless individuals, or that temporary housing diverts vital resources from more permanent solutions. But the city's latest permanent housing project will take three years to complete.

"In the meantime, we have a lot of people living on the streets. What do you do for them?" says San Diego Councilman Chris Ward, who pushed the city to open temporary housing when the outbreak was first declared in April. "This hepatitis A outbreak has given us a new heightened state of emergency on top of what is already a humanitarian crisis."

As with so many crises, this one targets a vulnerable population: unsheltered homeless people, who often wait hours in line at shelters before being turned away.

Still, some policymakers worry that authorizing homeless camps is not sustainable. It took San Diego Mayor Kevin Faulconer months to agree on a temporary housing plan, the first of its kind in the city. In San Diego, city council members and shelter owners alike subscribe to the tenets of Housing First, a Housing and Urban Development-sanctioned approach started under George W. Bush that prioritizes permanent supportive housing over treatment for health issues like addiction.

This approach can help residents navigate the health-care system in the long term. "In the Housing First approach, you offer people what they want, and, if it's housing, they have housing with no strings attached," says Suzanne Wenzel, a professor of social work at the University of Southern California who studies the health-related needs of the homeless. "I think there would be very little argument with the notion that there's much less risk of an outbreak like this or other epidemics, whether it's tuberculosis or HIV, when people have their basic, fundamental needs met."

But most advocates agree temporary housing is better than the alternative: Before the camps opened in San Diego, officials launched emergency protocols to stem the spread, busting up renegade encampments in order to blast the pavement with bleach. Police issued 50 citations a week in September—up from the usual 30, according to the Associated Press—and arrested those who refused to leave.

San Diego police lieutenant Scott Wahl says these measures were necessary. "Right now our priority is getting on top of this outbreak that's killing people," he says. "We cannot just sit back and allow people to die living in the conditions that they're in."

Still, homeless advocates and local media have questioned the wisdom of busting up communities and scattering their residents, especially amid an outbreak of a highly contagious disease.

With housing rates soaring and gentrification on the rise, cities across California have experienced an increase in homelessness, specifically among the unsheltered. San Diego's latest point-in-time homelessness count found that the number of unsheltered individuals increased by 64 percent from last year in the downtown area, leaving thousands to cram into camps. There are similar trends in San Francisco, Santa Cruz, and Los Angeles, and public officials in all of those cities have been braced for an outbreak.

In an environment like this, hepatitis A can be deadly. People living on the streets who are using drugs may have an underlying health condition or liver disease, like hepatitis C, which makes them more susceptible. "Just the experience of being homeless can worsen conditions one already has and bring on new problems," Wenzel says.

The hepatitis A vaccine is extremely effective, but public-health officials say it can be difficult to reach people who are homeless to offer the vaccine. The California Department of Health cites "distrust of public health authorities, lack of concern about the disease, mental illness, and other factors."

This may be the case in San Diego. PATH, a local non-profit, sent nurses out with the local police to help vaccinate people on the streets, but director Jonathan Castillo noted that it "takes some persistence" to get people to accept the vaccine.

However, what's often perceived as stubbornness can actually be the result of working within an unfriendly system. In the early days of social work, experts pegged the term "service resistance"—the idea that you can't help somebody on the street because they're going to refuse help. According to Wenzel, this is a mostly a myth.

"There might be discrimination; [providers] might be biased against serving people who might be actively hallucinating or who might not smell very good," she says. "We have to be sure that we are willing as a society and as providers to meet those individuals where they are when we extend a helping hand and make sure that we're not stigmatizing them."

Moreover, treatment can come at a price: Shelters with medical clinics sometimes bar people who can't kick an addiction; clinics cannot always meet a client's mental-health needs; and, in the case of outbreak, police bust encampments without notice in order to halt the spread, leaving people without a place to sleep or store their belongings.

"We expect [people on the streets] to come to our model of health care," says Seth Kurzban, a University of Southern California professor studying homelessness and mental health. "We don't do a lot to utilize the strengths or conditions that people we're trying to help are in ... like treating larger groups within a social network, as opposed to treating individuals."

In the middle of a deadly outbreak, cities like San Diego have a legal right to sweep the streets. However, the same places that spread disease—tent cities and encampments—might be uniquely equipped to fight it.

Plenty of research shows that social networks, like those fostered in homeless encampments, actually boost mental and physical health, whereas a National Academy of Sciences study determined that social isolation is directly linked to increased morbidity and mortality. In Denver, two researchers studying a 2012 camping ban found that eviction from "hard-fought places of safety and security" disrupts patterns of hygiene and social interaction.

A resident of the Alpha Project campsite walks between tents. (Photo: Alpha Project)

These studies suggest that cities must be careful about how they disband homeless camps—or they shouldn't do it at all. Years before San Diego launched its temporary housing plan, Portland and Seattle embraced authorized encampments; officials in Los Angeles, San Jose, and Sacramento have considered similar plans.

Suzanne Skinner, a homeless rights advocacy lawyer at Seattle University, says the approach has worked for Seattle. When a homeless advocacy group set up camp on public property in 2015, in what Skinner calls a "guerilla" move, the city decided to authorize it. Then city counsel, Skinner settled that lawsuit—a decision she says has improved sanitation, security, and community. Residents have access to water, electricity, and regular garbage pick-up. And, because they're no longer camping under freeways, service providers have been able or willing to contact them.

"The bottom line is it would be wonderful if we had all the housing needed, but we don't," she says. "These West Coast cities are booming. You can't build fast enough and cheaply enough to deal with the need. That's where these more creative solutions, interim solutions, have sprung up."

So San Diego will settle for tents. It's little consolation for unsheltered people and their doctors, like Norris, who lost a patient of a year and a half to the disease. The outbreak is slowing, but he still has clients. The streets are as crowded as ever.

Over at the public works yard, 181 people are going on with their lives. Families have set up camp in individual stalls, health-care providers and social workers make daily rounds, and five residents have already been placed in permanent housing. Alpha Project Chief Operating Officer Amy Gonyeau, whose non-profit oversees the campsite, says that, after years of stalemate, this move is "amazing"—not a solution, but a start.

"We've never seen the political will, the political drive to do something and do something quickly," Gonyeau says. "This is the first time I've seen the community and the residents really involved and investing in the problem. It's really optimistic to see things happen."

On a late October afternoon, about 45 homeless children shuttled from school to the camp, where they could eat and sleep with their families. Toddlers played on foam mats spread across the worn concrete, and elementary school kids gave interviews to the local news. A 10-year-old girl told a KPBS reporter that she and her sister could sleep better here than in a downtown park, where they had to continually move out of a sprinklers' path to avoid getting drenched. Now there's water where she needs it: in a shower and a sink.