Meanwhile, Shannon Bynum’s son, Kamari, 10, and daughter, Keyari, 8, who live nearby, are back on the Bayside MLK campus. Bynum had warned them, however, that if he heard they weren’t wearing masks, they’d have to learn remotely, too.

The two households, less than 3 miles apart, have found different answers to one of the most perplexing questions this fall: Should parents send their children back to school for classes during an ongoing pandemic or keep them at home?

At Bayside MLK, a K-8 school serving the ethnically and economically diverse community of Marin City, 103 children are attending class in person, including the Bynum children. The Mazariegos kids are among 12 learning remotely.

In March, the coronavirus consigned nearly all of the nation’s 55 million schoolchildren to home schooling. One by one, school districts across the country are weighing the risks of reopening. Some that have reopened have seen a among students who returned to class.

Bayside MLK was one of 15 Marin County schools that received waivers from the local public health department to reopen full time on Sept. 8, but officials gave parents the choice whether to send their children to campus or keep them home.

The start of classes was delayed for a week when one school employee contracted the virus, said Principal David Finnane. Once they started, the challenges mounted.

“This is the most mind-numbing time I’ve ever had as an educator,” said Finnane, who’s been a school principal for two decades.

“These are crazy days of temperature checks, telling third grade Jenny she entered the second grade gate at the wrong time, telling Xavier to use sanitizer on his elbow after he sneezes, reminding students not to touch this thing or that thing. It’s a job this school has never had to do and now we’re doing it every day, all day long.”

Health and safety protocols enacted by the school include staggered arrival times for students (via parent drop-offs), smaller classes, spaced-out desks, routine temperature and health checks, and an intensified cleaning schedule.

Mazariegos, 52, spent a difficult summer deciding whether to send Emily, 12, Ezekiel Jr., 10, and 7-year-old Evelyn back to class if and when school reopened in the fall.

But her husband, Ezekiel, a 42-year-old construction worker, had made up his mind. “He said, ‘Are you crazy? We can’t send our kids back to school without a vaccine,’” she recalled. “‘How do we know they’d be safe?’”

Mazariegos, who was a schoolteacher in her native Guatemala but now stays at home with her kids, has juggled the roles of teacher, tech consultant and even hall monitor in recent weeks.

School hadn’t been back in session for a week before her home Wi-Fi connection crashed. The two eldest kids could not connect to their Zoom instruction sessions, so Mazariegos called the school for help. To make sure they didn’t resort to computer games in the interim, she gave them textbooks to read.

“The phone was ringing, the kids were all calling my name from different rooms,” she said. “It was crazy.”

Single father Bynum, on the other hand, chose to send his two kids back to school.

“Kids learn from other kids, not just teachers,” said the 29-year-old real estate developer. “In school, they know what’s expected of them. It’s the best place for them to be.”

Finnane, the principal, had hoped all 115 students would return to classrooms. “Many kids doing distance learning just don’t have the same support network,” he said. “They might not have the resources, a quiet place to work, a supportive adult right there who can mentor and encourage them.”

And then there are the technical issues. Students who have stayed at home have experienced internet failures, Zoom glitches and computer bandwidth problems — “or when a teacher gives out the wrong Zoom link, all of which has already happened,” Finnane said.

A recent study by the on the educational challenges posed by the pandemic found that remote-learning programs are effective only if students have consistent access to the internet and computers and if teachers receive targeted training and support for online instruction.

While researchers acknowledged the risk of virus infection is greater at school, they found that students who have not returned to the classroom are falling behind.

“Children’s academic performance is deteriorating during the pandemic, along with their progress on other developmental skills,” the study said.

When Bayside MLK resorted to remote teaching for the entire school in the spring, officials identified 41 students who were demonstrably falling behind, Finnane said. Standardized tests given to students this academic year will provide a report card on students’ success, he added.

Over the summer, Bayside MLK teachers received one day of training to perform online classes in addition to their at-school duties.

“A full day of online-learning training helps, but when it comes to the constant challenges of teaching, especially those with special needs, I’m not sure that’s sufficient,” said Emma García, who co-authored the Economic Policy Institute study.

Mazariegos knows this all too well. Her daughter Emily has comprehension issues that have kept her back a grade.

A quiet girl who loves animals and science, and who one day wants to become a veterinarian, the sixth grader relies on her mother to spend extra time reviewing lessons.

“She has to touch and feel things, to have a lesson demonstrated before she can best understand,” her mother said. “She can’t just sit in front of a computer reading some concept over and over and over.”

Mazariegos understands her daughter may fall another year behind but says she’ll take that chance. “If we lose her to COVID-19, that year is nothing,” she said. “This is a hard decision for any mother. But Emily is so afraid of the virus that sending her back to school would just be traumatizing.”

Bynum, whose fourth grade son, Kamari, suffers from attention deficit disorder, believes the classroom is the best place for the restless child. In March, when the school was closed at the start of the pandemic, Bynum got a taste of the demanding task of being a teacher.

“With two kids in two different grades asking me questions, I struggled to explain things,” he said. “It would have been easy for me to just tell them the answer, but the object of a good instructor is to teach them to find it themselves. And I had to learn that.”

Bynum has developed his own protocol. He requires his children to shower the moment they return from school, and they get regular lectures about hand-washing and common sense.

“If I even suspect they’re not wearing their masks, I’ll say, ‘OK, it’s back to the house and your laptop,’ and they’ll say, ‘Oh yeah, Dad, I’m wearing my mask.’”

Mazariegos remains comfortable with her decision, especially when she reads about all the COVID-19 outbreaks at schools and colleges.

Her kids aren’t so sure.

Second grader Evelyn, an outgoing girl, recently joined a Zoom lesson that included classmates she hadn’t seen in person for months.

“She cried,” her mother said. “She wanted to be back at school to see her friends.”

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But Warren won’t go near a hospital, even though she says her wrist hurts every day.

“If I go back to the hospital, I’ll get COVID. Hospitals are full of COVID people,” says Warren, a former film director and author of the book “How to Make Your Audience Fall in Love With You.”

“Doctors say, ‘Come back for therapy,’ and my answer is, ‘No, thank you.’”

Many, many patients like Warren are shunning hospitals and clinics. The coronavirus has so diminished trust in the U.S. medical system that even people with obstructed bowels, chest pain and stroke symptoms are ignoring danger signs and staying out of the emergency room, with potentially mortal consequences.

A by the Centers for Disease Control and Prevention found that emergency room visits nationwide fell 42% in April, from a mean of 2.1 million a week to 1.2 million, compared with the same period in 2019.

A Harris found roughly 1 in 4 adults experiencing a heart attack or stroke would rather stay at home than risk getting infected with the coronavirus at the hospital. These concerns are higher in Black (33%) and Hispanic (41%) populations, said Dr. Mitchell Elkind, president of the American Heart Association and a professor of neurology and epidemiology at Columbia University.

Perhaps even more worrisome is the drastic falloff of routine screening, especially in regions hit hard by the virus. Models created by the medical research company IQVIA predict delayed diagnoses of an estimated 36,000 breast cancers and 19,000 colorectal cancers due to COVID-19’s scrambling of medical care.

At Hoag Memorial Hospital Presbyterian in Newport Beach, California, mammograms have dropped as much as 90% during the pandemic. “When you see only 10% of possible patients, you’re not going to spot that woman with early-stage breast cancer who needs a follow-up biopsy,” said Dr. Burton Eisenberg, executive medical director of the Hoag Family Cancer Institute.

Before the epidemic, Eisenberg saw five melanoma patients a week. He hasn’t seen any in the past month. “There’s going to be a lag time before we see the results of all this missed care,” he said. “In two or three years, we’re going to see a spike in breast cancer in Orange County, and we’ll know why,” he said.

Dr. Farzad Mostashari, former national coordinator for health information technology at the U.S. Department of Health and Human Services, agreed. “There will be consequences for deferring chronic disease management,” he said.

“Patients with untreated high blood pressure, heart and lung and kidney diseases are all likely to experience a slow deterioration. Missed mammograms, people keeping up with blood pressure control — there’s no question this will all cause problems.”

In addition to fear? Changes in the health care system have prevented some from getting needed care.

Many medical offices have remained closed during the pandemic, delaying timely patient testing and treatment. Other sick patients lost their company-sponsored health insurance during virus-related job layoffs and are reluctant to seek care, .

A found that 79% of cancer patients in treatment had experienced delays in care, including 17% who saw delays in chemotherapy or radiation therapy.

“Many screening facilities were shuttered, while people were afraid to go to the ones that were open for fear of contracting COVID,” said Dr. William Cance, chief medical and scientific officer for the American Cancer Society.

And then there are patients who have fallen through the cracks because of the medical system’s fixation on COVID-19.

Dimitri Timm, a 43-year-old loan officer from Watsonville, California, began feeling stomach pain in mid-June. He called his doctor, who suspected the coronavirus and directed Timm to an urgent care facility that handled suspected COVID patients.

But that office was closed for the day. When he was finally examined the following afternoon, Timm learned his appendix had burst. “If my burst appendix had become septic, I could have died,” he said.

The degree to which non-COVID patients are falling through the cracks may vary by region. Doctors in Northern California, whose hospitals haven’t yet seen an overwhelming surge of COVID-19 cases, have continued to see other patients, said Dr. Robert Harrington, chairman of the Stanford University Department of Medicine and outgoing president of the American Heart Association. Non-COVID issues were more likely to have been missed in, say, New York during the April wave, he said.

The American College of Cardiology and American Heart Association have launched campaigns to get patients to seek urgent care and continue routine appointments.

The impact of delayed care might be felt this winter if a renewed crush of COVID-19 cases collides with flu season, overwhelming the system in what CDC Director Robert Redfield has predicted will be “one of the most difficult times that we’ve experienced in American public health.”

The health care system’s ability to handle it all is “going to be tested,” said Anthony Wright, executive director of Health Access California, an advocacy group.

But some patients who stay at home may actually be avoiding doctors because they don’t need care. Yale University cardiologist and researcher Dr. Harlan Krumholz believes the pandemic could be reducing stress for some heart patients, thus reducing heart attacks and strokes.

“After the nation shut down, the air was cleaner, the roads were less trafficked. And so, paradoxically, people say they were experiencing less stress in the pandemic, not more,” said Krumholz, who wrote an April op-ed in The New York Times headlined “While sheltering in place, they were eating healthier, changing lifestyles and bad behaviors,” he said.

At least some medical experts agree.

“The shutdown may have provided a sabbatical for our bad habits,” said Dr. Jeremy Faust, a physician in the division of health policy and public health at Boston’s Brigham and Women’s Hospital. “We’re making so many changes to our lives, and that includes heart patients. If you go to a restaurant three times a week or more, do you realize how much butter you’re eating?”

While some patients may be benefiting from a COVID-19 change of regimen, many people have urgent and undeniable medical needs. And some are pressing through their fear of the virus to seek care, after balancing the risks and benefits.

In March, when the virus took hold, Kate Stuhr-Mack was undergoing a clinical trial at Hoag for her stage 4 ovarian cancer, which had recurred after a nine-month relapse.

Members of her online support group considered staying away from the facility, afraid of contracting the virus. But Stuhr-Mack, 69, a child psychologist, had no choice: To stay in the trial, she had to keep her regular outpatient chemotherapy appointments.

“We all make choices, so you have to be philosophical,” she said. “And I thought it was far more risky not to get my cancer treatment than face the off-chance I’d contract COVID on some elevator.”

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Beginning in March, the COVID-19 pandemic shuttered their popular Gourmet Italia restaurant in Temecula, a wine-growing community of 115,000 southeast of Los Angeles. Dozens of employees were laid off; food stocks quickly became outdated.

They began bleeding cash — about $20,000 every day in lost business, rent and sundry other payments on Gourmet Italia and their other properties, a winery and the pizzeria Spuntino.

While desperate to reopen, the couple also realized the perils involved in serving food to the public with a dangerous pathogen on the loose. The Centers for Disease Control and Prevention’s guidelines were confusing enough for the general public. For restaurants trying to keep loyal patrons safe, the lack of clarity was maddening.

What precisely did social distancing mean inside their restaurant, the Prestifilippos wondered. Did customers expect servers, chefs and busboys to wear masks? How vigilantly did they have to sanitize counters and tables? How often should employees wash their hands?

“It was stressful,” said Charity. “While we understood the government itself was trying to figure all of this out, nobody could give us any hard answers. And we couldn’t devise a plan of attack without permanent information.”

After being advised he could seat his restaurant at only 50% capacity, Alex said, he was later informed there was no capacity limit, as long as tables were spaced 6 feet apart.

“Government health officials were giving owners a moving target. Even restaurant associations were having a hard time getting a handle on the right process,” said Phil Mott, a Colorado-based restaurant consultant. “Owners faced retraining all their employees, but they weren’t even sure what that training entailed.”

The Prestifilippos recently reopened Gourmet Italia and Spuntino, but not without much anguish and deliberation, and many tough decisions.

Beginning in April, Charity joined a weekly virtual meeting with dozens of other restaurant owners in the tightknit tourist community, dotted with privately owned wineries and mom and pop eateries. Many feared they would be forced to close for good if they didn’t reopen soon. Some wanted to “go rogue,” opening collectively and gambling that heath officials would not close them all down.

In the end, the group of Temecula restaurant owners decided to wait, using the time to develop a list of preferred practices for the future, precautions that ranged from providing hand sanitizer and wipes to replacing traditional salt and pepper shakers with disposable packets.

They agreed to document bathroom cleaning schedules and open the parking lot to outdoor tables so customers could keep their distance. Cafes with counter service considered installing plexiglass barriers between diners.

“The idea was to do more than you would probably need — so customers could see that you were doing your best to create a safe place,” said Charity. “But there were also business considerations. Could you be as quick and efficient with your service if you have to take all these precautions? How was all this going to work?”

After emigrating from Sicily, Alex, 51, learned English and opened his first restaurant in 1999. He eventually developed a 7,000-square-foot space with high-end Italian cuisine and white linen tablecloths that as a romantic dining spot.

Charity, 47, was one who found romance there. She came in first as a customer, then met Alex, and they fell in love.

The Prestifilippos received about $300,000 in economic assistance through Small Business Administration loans. Still, it felt as if they were leaking hard-earned money. And the projected costs of implementing all these health precautions — between $500 and $1,000 a day — brought sticker shock.

“I showed Alex the figures and he said, ‘Are you kidding me?’” Charity recalled.

Not only were supply prices escalating with increased demand, but also there were long waits for items such as specialized thermometers that could be applied to the foreheads of employees, and possibly customers, which cost $180 or more — if you could get them. They also needed gallons of sanitizer, masks, gloves and who knew what else?

“I just spent $2,800 on peroxide for the two restaurants and I have no idea how long that’s going to last,” Alex said. Masks cost $1.50 each, and the chefs, servers and busboys use several each shift, he said.

Alex decided not to raise prices to cover the costs. That would not be fair to his customers, he said.

On May 30, after months of quarantine, customers formed a line outside for Gourmet Italia’s first lunch seating.

The diners encountered a coronavirus safety plan that had been months in the making. For starters, the owners kept the front doors open so customers didn’t have to touch the handles and installed hand-sanitizing devices at the entrance.

Servers and busboys wore masks, and the bar and kitchen staff donned gloves as well. Only after tables were seated were plates and wrapped silverware presented. Menus were sanitized after each use, and salt and pepper shakers were brought on demand — and quickly wiped down. Tables were moved into the bar area to create extra distance, and workers patrolled the restaurant to clean surfaces. All 35 workers returned from layoffs.

So far, business has been down. Alex handled 150 diners during the Saturday night of the reopening and brought in $10,000, down from 450 customers and $30,000 on a typical Saturday before the shutdown. Street protests against police violence in Temecula held down the opening-day crowd, he said.

Alex described the opening-night atmosphere as like a family reunion, with people constantly approaching to congratulate him. He had to duck inside his office to get any paperwork done. Alex said he’s sure no customer will get sick in his restaurant. “We have one employee whose only job all day is to sanitize menus, chairs, tables and door handles, and clean the bathroom every half-hour,” he said. “I feel safe.”

And though he hails from an Italian culture of embraces and social kisses, Alex has chosen to put safety over traditional social graces.

“I told myself, ‘I’m not gonna hug,’” he said. “It’s very important to respect the code. I let my employees know — elbow bumps only. No hugs. No hands.”

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The drugs were cheap, and the customers — mostly from Mexico and Central America — did not need prescriptions to buy them. Some of the products featured brand names and colorful packaging that immigrants knew well from their home countries — including Ciprofloxacina, a potent antibiotic, and Dolo Nervi Doce — translated as “Pain Nerve 12” — an injectable B-complex vitamin taken for fatigue.

Many were sheer counterfeits. Others, though legal south of the border, were not approved for sale in the United States. Some had expired. Still others would have been legal if sold by people licensed to do so — but none of the sellers held pharmacist licenses or any other medical credential.

L.A. County authorities seized the drugs last month in an operation that led to the . Their haul included 100,000 foreign-made pills, compounds and injectable medicines they said could have caused serious harm or even death to consumers.

Immigrants, not just from Hispanic countries but from all over the world — and some non-immigrants too — are purchasing a wide array of illegal medications in black markets that are common not only in Southern California but in states such as Arizona, Maryland, Texas, Virginia and Washington, according to law enforcement officials and others familiar with the trade.

“We’re seeing this in all communities across the country that don’t have access to health care services,” said Adolph Falcon, executive vice president of the Washington, D.C.-based National Alliance for Hispanic Health, which provides information and health-related assistance to Hispanic communities nationwide. “These products prey on the desperation of people who can’t afford to see a doctor or go to a legitimate pharmacy.”

The current political climate in the U.S. is also pushing some immigrants to the black market, doctors and researchers say.

“Many patients are afraid they’ll be deported if they come into our clinics, so they buy from the street, said Dr. Anjali Mahoney, the Orange County, Calif., regional medical director for AltaMed Health Services, a large chain of federally funded community clinics whose patients are primarily Latino.

“People are paying for something that doesn’t work and could even harm them, when they could have just as easily come to a clinic and get safe care with a doctor,” Mahoney said.

She added that every one of AltaMed’s 23 clinics in Southern California has reported problems with off-the-street medications. One Latina woman was hospitalized after taking an opiate advertised as blood pressure medicine, she noted.

These dubious products targeted by law enforcement are different from the legitimate prescription pharmaceuticals every year by millions of U.S. residents who cross the border into Canada and Mexico or use licensed online pharmacies abroad to buy their medications at a fraction of the price they would pay in this country.

Although those imports are also technically illegal, from the Food and Drug Administration allow federal agents to take a hands-off approach.

That’s not the case with wares peddled on the streets by often unscrupulous operators.

“Counterfeit medicines may contain the wrong ingredients, contain too little, too much or no active ingredient at all — or contain other, potentially life-threatening hidden ingredients,” said Jeremy Kahn, an FDA spokesman.

Drug companies and pharmacies also have an interest in disrupting the distribution of such medications. The nationwide value of this pharmaceutical black market is difficult to gauge, but it may displace billions of dollars’ worth of legally approved medicine, said Roger Bate, an economist at the American Enterprise Institute and author of the book “Phake: The Deadly World of Falsified and Substandard Medicines.”

Between October 2017 and July 2018, FDA officials confiscated nearly 22,000 packages containing illegal pharmaceuticals from international mail facilities, Kahn said. He said authorities routinely impound various opioids as well as dietary supplements laced with erectile dysfunction drugs and other dubious products. They come from India, China and across Europe — “just about everywhere,” Kahn said.

The medications seized by the FDA are just the tip of the iceberg. The agency estimates it is able inspect sent via international mail that are believed to contain drugs. And many illicit products arrive not through the mail but in suitcases, cars, trucks or cargo ships, authorities say.

The purveyors of these “dodgy medicines” are “myriad and global,” including Chinese and Indian manufacturers, Russian mobsters, Mexican gangs and domestic U.S. groups, said Bate. “There are charlatans and odious actors who don’t mind if their product kills children, adults or breadwinners of entire families.”

Nationwide, many local police departments lack the resources or mandate to investigate sales of illicit pharmaceuticals; otherwise, the number of arrests would probably be much higher, public and industry officials say.

“Not enough attention is paid to this issue,” said Jon Roth, CEO of the California Pharmacists Association. “It’s probably largely operating in the dark shadows of every community. If we put the resources there, we’d see how wide it is.”

L.A. County is one jurisdiction paying attention. In 1999, it formed the Health Authority Law Enforcement Task Force (HALT), after two Latino infants died from taking illegal medications. HALT is the group that made the August arrests.

So far this year, it has arrested 34 people in 54 cases, 48 of them involving illegal pharmaceuticals sold to immigrants, said Erick Aguilar, one of the investigators.

Illegal pharmaceuticals are being sold to immigrants in “every rural swap meet you can find,” and the sellers are becoming more sophisticated, Aguilar said. “They’re better at hiding it,” and “they’re more careful who they sell to.”

In February 2019, three men – two in Southern California and one from Salem, Ore. – to the illegal importation and sale of $11 million worth of pharmaceutical-grade erectile dysfunction drugs falsely marketed across the U.S. as herbal remedies for men. One of the perpetrators imported from China powdered tadalafil, the active ingredient in , and used it to make 5.5 million pills with up to 14 times the level contained in Cialis, according to the FDA.

In 2017 and 2018, the Phoenix police department’s organized-crime commercial unit raided 30 pharmacies in Latino neighborhoods, confiscating “millions of dosages of illegal medicines, some of them outdated by 15 years,” said Detective Sgt. David Lake, who led the unit.

But not all the sellers were members of organized crime. Lake recalled one woman who genuinely believed she was doing something positive for her community by distributing black-market birth control pills.

“She said local girls were having too many babies, and she wanted to help them, but the babies kept being born,” Lake recalled. “When I told her the drugs were counterfeit, she cried for a half-hour straight.”

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Snyder, a Monterey, Calif., mother of two, was a so-called anti-vaxxer for many years, adding her voice to those that rejected mandatory vaccinations for school-age children.

She later realized she was wrong and in 2014 founded a pro-vaccination Facebook group called “Crunchy Front Range Pro-Vaxxers,” which she administers. It is an invitation-only site on which approximately 1,100 members exchange views and information.

Snyder, 38, is also an advocate for pending California legislation, , which targets bogus medical exemptions that allow unvaccinated children to attend school. The number of medical exemptions issued by physicians has in recent years. The Medical Board of California is doctors for issuing questionable exemptions for children.

Meanwhile, some infectious diseases once thought under control are breaking out again because parents failed to have their children vaccinated. Between Jan. 1 and July 25, were reported across 30 states, the most since the disease was in 2000, according to the Centers for Disease Control and Prevention. California has seen 62 new measles cases this year.

We talked to Snyder about her transformation.

As a former opponent of mandatory childhood vaccines, can you describe the mindset?

Anti-vaxxers have been around for a long time, but social media makes it easier to get into a loop. And once you’re there, it’s hard to see outside of it. Algorithms just show you more of what you’re already looking for. If you start searching anti-vaccination stories, that’s what starts popping up on your tagline. You start to think, “Oh, my God, there’s all these people and there’s so much of this going on.” But if you have a chance to peel back from that, you see that it’s actually a very small portion of the population who are really, really loud. The fear makes you angry and it makes you lash out. Once you get into that state, it’s easy to stay there.

Describe a moment when you were in that state of mind.

When my daughter was born, I refused . I remember lying there with my daughter in my arms, and the nurses said, “Hey, we’re going to give her the vitamin K,” and I said, “No, we’re not doing that.” They made me sign a form that said I was going against the recommended medical care. At the time, the anti-vaxxer voices in my head said they were trying to coerce me into doing something dangerous for my child. They told me I was going to have to stay in the hospital longer for observation. I saw that as trying to force me to inject my child with this poison.

What activities did you engage in as an anti-vaxxer?

I joined some social media groups and would get together with some of those mothers who believed what I did. We used to call the pro-vaccination mothers “sheeple.” You’d ask them, “Have you thought about your stance? Have you even done any research?” Because when you’re in that anti-vax mindset, you spend all these hours on the internet, reading studies. I’ve come to realize that a Google search isn’t really research. Most times, you’re not reading an entire study, but only the abstract.

What changed your mind on vaccinations?

In the summer of 2014, I was in one particular anti-vaxxer Facebook group, and there was a debate going on about vaccines, and I started to notice that every time someone disagreed with them, the core members got belligerent, going straight to personal attacks. I also noticed that every single point they brought up had this immense conspiracy to go along with it. By that point, I’d started to think, “Do I really believe in all these conspiracies? Am I really that afraid, or can I go back and look at the evidence again?” By then, my daughter was 8 months old, and I just got over the fear I had as a first-time mom. I realized that my daughter was going to be OK.

How do you think the vaccination fight will play out in California and nationally?

I think California is setting a precedent for vaccine laws across the country. We’re making sure that medical exemptions for vaccines are not being bought, and that’s a very serious problem. Other states have seen the work we’ve done and they’re working on their own legislation. We’ve come to realize that unless we get more vocal about our pro-vaccine stance, the anti-vaccine voices just get louder and louder. I sometimes refer to anti-vaxxers as the drunk drivers of public health. They’re dangerous.

What do you say today to the anti-vaxxers you once aligned with?

I tell people that I understand their fears. I understand that parenting is very difficult, and all of us truly want the best for our children. I also know that the evidence is out there when people are willing to let their guards down. And I’m always happy to share real solid scientific evidence with people who want to do their critical thinking for themselves. I’m hoping people come around. I did. But we can’t force anybody. We just want to protect everyone else.

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FRESNO, Calif. — On the 15-mile drive between his two Central Valley medical clinics, Dr. J. Luis Bautista often passes armies of farmworkers stooped over in the fields, picking onions, melons and tomatoes.

Most of the 30,000 annual office visits to his small staff of doctors and nurses in downtown Fresno and the nearby rural town of Sanger are by these farmworkers. Many of them are undocumented.

The 64-year-old physician has personal insight into the struggles of these laborers: He was once one of them. As a boy, he picked fruit alongside his parents and nine siblings in Ventura County. The family made $4,000 a year back then, a little over $30,000 in today’s dollars — rarely enough to spare for doctor’s visits.

These days, Bautista sees that many farmworkers still lack the transportation, money or time off from work to treat injuries, let alone seek preventive medical care. Plus, there is the heightened fear that by seeking medical treatment they might be exposed to federal immigration authorities.

“I pledged in medical school to help these people in the farm fields,” said Bautista. “I knew how it felt not to have anything, not to have the money to go to a doctor.”

Now he treats them whether or not they have money — or legal documents. “We never say no to patients,” he said.

President Donald Trump’s campaign pledge to immigrants who have entered the U.S. illegally has fostered fear among farmworkers nationwide. Terrified they’ll be caught in an immigration dragnet, farm laborers across the San Joaquin Valley without U.S. citizenship or official documents avoid driving to see a doctor or visit an emergency room.

Although California the state’s cooperation with U.S. immigration enforcement, some jurisdictions outside the Central Valley have decided to participate in federal efforts to detain undocumented workers. Many here fear that local officials will soon join them, Bautista said.

Farmworkers also worry that personal information housed in doctors’ offices could find its way into the hands of federal authorities. And some fear that if they enroll in programs for low-income residents, they’ll later be denied permanent residence, the so-called green card, or U.S. citizenship.

The Trump administration has proposed a federal rule change that would make it harder for legal immigrants to get green cards if they have received certain public assistance benefits, including food stamps, housing subsidies and Medicaid — the government-funded health care program for people with low incomes.

“Many people don’t know what the government will do,” Bautista said. “They tell me that one reason they don’t go to the doctor is over fear they’ll be reported.”

Bautista’s two clinics provide a haven for immigrants burdened by these concerns. Patients are never asked about their immigration status, and the staffs have set up protocols in case the offices are raided by immigration authorities.

“I feel secure with him,” said Julia Rojas, a 45-year-old undocumented mother of five who has picked oranges in Fresno County for two decades. “He’s one of us.”

Bautista accepts as payment whatever his patients can offer: onions, handmade key chains, eggs, even live chickens.

Dan Baradat, a Fresno personal injury lawyer who has handled cases involving migrant workers, said Bautista’s clinics are indispensable to the Central Valley’s poorer residents. “They’re stand-up people who provide care to people who could not otherwise afford it,” he said.

Bautista’s clinics are among a network of federally supported community clinics that provide care for nearly 1 million migratory and seasonal agricultural workers and their families around the U.S. But few providers have a better connection to the community they serve than Bautista, who in 2013 founded a nonprofit that raises money to assist low-income farm families with food and clothing, and provides scholarships to send their children to college.

Born in Fresno, Bautista was deported with his parents when he was just 3 months old. He lived in Mazatlán, Mexico, until he returned to the U.S. at age 12.

In 1979, at age 24, he was picking lemons when his mother came running out to the fields with the letter announcing he’d been admitted to medical school. She’d always been big on education for her 10 children.

Bautista attended the in Milwaukee and did his residency in internal medicine at the University of Nevada-Reno.

Today, two of Bautista’s four sons are also doctors. A third son, whom he adopted, is a physician assistant, as is his son-in-law, who was a farmworker before joining the clinic. His fourth son is the clinic manager. All of them know that fear of deportation is affecting farmworkers’ health.

Dr. Ed Zuroweste, founding medical director of the nationwide Migrant Clinicians Network, said a recent survey of providers within the organization underlined these fears.

“What we’re seeing on the front lines is that farmworkers and their families are not coming in for regular appointments as frequently as they had before,” he said.

Bautista said many undocumented farmworkers rely on home remedies to treat ailments such as diabetes and high blood pressure, often until it’s too late for effective medical treatment. “By the time I see many diabetic patients, their feet are already necrotic and we have to amputate,” Bautista said. “It’s terrible to see.”

Jose Jimenez, a former farmworker, said his father, who is not in this country legally, was too afraid to drive to Bautista’s office, even after developing signs of melanoma on his face. His dad’s fears were heightened last year following the , the parents of six children, whose van overturned while they were fleeing federal immigration officers in nearby Delano.

“He was even afraid to drive to the supermarket,” said Jimenez, 30. “He knew that if he was picked up, he’d be deported. For a close-knit family like ours, that would mean losing everything.” But Jimenez finally persuaded his father to visit Bautista.

Bautista’s clinics are on guard against U.S. immigration officials, known in this community as la migra.

Law enforcement officials requesting records are asked for a warrant, and staff members are on the lookout for intruders. “By the time any ICE officers got inside the office,” Bautista said, “we’d have people hiding in the restrooms.”

Julia Rojas said her fears of deportation almost killed her. Years ago, before she began seeing Bautista, she chose to ignore the piercing pain in her lower abdomen. In the U.S. without papers and afraid to drive, she spent nearly a day drinking mint leaves in hot water — a remedy her mother used for stomach pain back in Mexico.

Unable to stand the spasms, she finally went to the nearest emergency room, where doctors removed her gall bladder. “Among undocumented workers in the fields, we have a dark little joke,” Rojas said. “You can survive out here. Just don’t get sick.”

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Meanwhile, Shannon Bynum’s son, Kamari, 10, and daughter, Keyari, 8, who live nearby, are back on the Bayside MLK campus. Bynum had warned them, however, that if he heard they weren’t wearing masks, they’d have to learn remotely, too.

The two households, less than 3 miles apart, have found different answers to one of the most perplexing questions this fall: Should parents send their children back to school for classes during an ongoing pandemic or keep them at home?

At Bayside MLK, a K-8 school serving the ethnically and economically diverse community of Marin City, 103 children are attending class in person, including the Bynum children. The Mazariegos kids are among 12 learning remotely.

In March, the coronavirus consigned nearly all of the nation’s 55 million schoolchildren to home schooling. One by one, school districts across the country are weighing the risks of reopening. Some that have reopened have seen a among students who returned to class.

Bayside MLK was one of 15 Marin County schools that received waivers from the local public health department to reopen full time on Sept. 8, but officials gave parents the choice whether to send their children to campus or keep them home.

The start of classes was delayed for a week when one school employee contracted the virus, said Principal David Finnane. Once they started, the challenges mounted.

“This is the most mind-numbing time I’ve ever had as an educator,” said Finnane, who’s been a school principal for two decades.

“These are crazy days of temperature checks, telling third grade Jenny she entered the second grade gate at the wrong time, telling Xavier to use sanitizer on his elbow after he sneezes, reminding students not to touch this thing or that thing. It’s a job this school has never had to do and now we’re doing it every day, all day long.”

Health and safety protocols enacted by the school include staggered arrival times for students (via parent drop-offs), smaller classes, spaced-out desks, routine temperature and health checks, and an intensified cleaning schedule.

Mazariegos, 52, spent a difficult summer deciding whether to send Emily, 12, Ezekiel Jr., 10, and 7-year-old Evelyn back to class if and when school reopened in the fall.

But her husband, Ezekiel, a 42-year-old construction worker, had made up his mind. “He said, ‘Are you crazy? We can’t send our kids back to school without a vaccine,’” she recalled. “‘How do we know they’d be safe?’”

Mazariegos, who was a schoolteacher in her native Guatemala but now stays at home with her kids, has juggled the roles of teacher, tech consultant and even hall monitor in recent weeks.

School hadn’t been back in session for a week before her home Wi-Fi connection crashed. The two eldest kids could not connect to their Zoom instruction sessions, so Mazariegos called the school for help. To make sure they didn’t resort to computer games in the interim, she gave them textbooks to read.

“The phone was ringing, the kids were all calling my name from different rooms,” she said. “It was crazy.”

Single father Bynum, on the other hand, chose to send his two kids back to school.

“Kids learn from other kids, not just teachers,” said the 29-year-old real estate developer. “In school, they know what’s expected of them. It’s the best place for them to be.”

Finnane, the principal, had hoped all 115 students would return to classrooms. “Many kids doing distance learning just don’t have the same support network,” he said. “They might not have the resources, a quiet place to work, a supportive adult right there who can mentor and encourage them.”

And then there are the technical issues. Students who have stayed at home have experienced internet failures, Zoom glitches and computer bandwidth problems — “or when a teacher gives out the wrong Zoom link, all of which has already happened,” Finnane said.

A recent study by the on the educational challenges posed by the pandemic found that remote-learning programs are effective only if students have consistent access to the internet and computers and if teachers receive targeted training and support for online instruction.

While researchers acknowledged the risk of virus infection is greater at school, they found that students who have not returned to the classroom are falling behind.

“Children’s academic performance is deteriorating during the pandemic, along with their progress on other developmental skills,” the study said.

When Bayside MLK resorted to remote teaching for the entire school in the spring, officials identified 41 students who were demonstrably falling behind, Finnane said. Standardized tests given to students this academic year will provide a report card on students’ success, he added.

Over the summer, Bayside MLK teachers received one day of training to perform online classes in addition to their at-school duties.

“A full day of online-learning training helps, but when it comes to the constant challenges of teaching, especially those with special needs, I’m not sure that’s sufficient,” said Emma García, who co-authored the Economic Policy Institute study.

Mazariegos knows this all too well. Her daughter Emily has comprehension issues that have kept her back a grade.

A quiet girl who loves animals and science, and who one day wants to become a veterinarian, the sixth grader relies on her mother to spend extra time reviewing lessons.

“She has to touch and feel things, to have a lesson demonstrated before she can best understand,” her mother said. “She can’t just sit in front of a computer reading some concept over and over and over.”

Mazariegos understands her daughter may fall another year behind but says she’ll take that chance. “If we lose her to COVID-19, that year is nothing,” she said. “This is a hard decision for any mother. But Emily is so afraid of the virus that sending her back to school would just be traumatizing.”

Bynum, whose fourth grade son, Kamari, suffers from attention deficit disorder, believes the classroom is the best place for the restless child. In March, when the school was closed at the start of the pandemic, Bynum got a taste of the demanding task of being a teacher.

“With two kids in two different grades asking me questions, I struggled to explain things,” he said. “It would have been easy for me to just tell them the answer, but the object of a good instructor is to teach them to find it themselves. And I had to learn that.”

Bynum has developed his own protocol. He requires his children to shower the moment they return from school, and they get regular lectures about hand-washing and common sense.

“If I even suspect they’re not wearing their masks, I’ll say, ‘OK, it’s back to the house and your laptop,’ and they’ll say, ‘Oh yeah, Dad, I’m wearing my mask.’”

Mazariegos remains comfortable with her decision, especially when she reads about all the COVID-19 outbreaks at schools and colleges.

Her kids aren’t so sure.

Second grader Evelyn, an outgoing girl, recently joined a Zoom lesson that included classmates she hadn’t seen in person for months.

“She cried,” her mother said. “She wanted to be back at school to see her friends.”

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But Warren won’t go near a hospital, even though she says her wrist hurts every day.

“If I go back to the hospital, I’ll get COVID. Hospitals are full of COVID people,” says Warren, a former film director and author of the book “How to Make Your Audience Fall in Love With You.”

“Doctors say, ‘Come back for therapy,’ and my answer is, ‘No, thank you.’”

Many, many patients like Warren are shunning hospitals and clinics. The coronavirus has so diminished trust in the U.S. medical system that even people with obstructed bowels, chest pain and stroke symptoms are ignoring danger signs and staying out of the emergency room, with potentially mortal consequences.

A by the Centers for Disease Control and Prevention found that emergency room visits nationwide fell 42% in April, from a mean of 2.1 million a week to 1.2 million, compared with the same period in 2019.

A Harris found roughly 1 in 4 adults experiencing a heart attack or stroke would rather stay at home than risk getting infected with the coronavirus at the hospital. These concerns are higher in Black (33%) and Hispanic (41%) populations, said Dr. Mitchell Elkind, president of the American Heart Association and a professor of neurology and epidemiology at Columbia University.

Perhaps even more worrisome is the drastic falloff of routine screening, especially in regions hit hard by the virus. Models created by the medical research company IQVIA predict delayed diagnoses of an estimated 36,000 breast cancers and 19,000 colorectal cancers due to COVID-19’s scrambling of medical care.

At Hoag Memorial Hospital Presbyterian in Newport Beach, California, mammograms have dropped as much as 90% during the pandemic. “When you see only 10% of possible patients, you’re not going to spot that woman with early-stage breast cancer who needs a follow-up biopsy,” said Dr. Burton Eisenberg, executive medical director of the Hoag Family Cancer Institute.

Before the epidemic, Eisenberg saw five melanoma patients a week. He hasn’t seen any in the past month. “There’s going to be a lag time before we see the results of all this missed care,” he said. “In two or three years, we’re going to see a spike in breast cancer in Orange County, and we’ll know why,” he said.

Dr. Farzad Mostashari, former national coordinator for health information technology at the U.S. Department of Health and Human Services, agreed. “There will be consequences for deferring chronic disease management,” he said.

“Patients with untreated high blood pressure, heart and lung and kidney diseases are all likely to experience a slow deterioration. Missed mammograms, people keeping up with blood pressure control — there’s no question this will all cause problems.”

In addition to fear? Changes in the health care system have prevented some from getting needed care.

Many medical offices have remained closed during the pandemic, delaying timely patient testing and treatment. Other sick patients lost their company-sponsored health insurance during virus-related job layoffs and are reluctant to seek care, .

A found that 79% of cancer patients in treatment had experienced delays in care, including 17% who saw delays in chemotherapy or radiation therapy.

“Many screening facilities were shuttered, while people were afraid to go to the ones that were open for fear of contracting COVID,” said Dr. William Cance, chief medical and scientific officer for the American Cancer Society.

And then there are patients who have fallen through the cracks because of the medical system’s fixation on COVID-19.

Dimitri Timm, a 43-year-old loan officer from Watsonville, California, began feeling stomach pain in mid-June. He called his doctor, who suspected the coronavirus and directed Timm to an urgent care facility that handled suspected COVID patients.

But that office was closed for the day. When he was finally examined the following afternoon, Timm learned his appendix had burst. “If my burst appendix had become septic, I could have died,” he said.

The degree to which non-COVID patients are falling through the cracks may vary by region. Doctors in Northern California, whose hospitals haven’t yet seen an overwhelming surge of COVID-19 cases, have continued to see other patients, said Dr. Robert Harrington, chairman of the Stanford University Department of Medicine and outgoing president of the American Heart Association. Non-COVID issues were more likely to have been missed in, say, New York during the April wave, he said.

The American College of Cardiology and American Heart Association have launched campaigns to get patients to seek urgent care and continue routine appointments.

The impact of delayed care might be felt this winter if a renewed crush of COVID-19 cases collides with flu season, overwhelming the system in what CDC Director Robert Redfield has predicted will be “one of the most difficult times that we’ve experienced in American public health.”

The health care system’s ability to handle it all is “going to be tested,” said Anthony Wright, executive director of Health Access California, an advocacy group.

But some patients who stay at home may actually be avoiding doctors because they don’t need care. Yale University cardiologist and researcher Dr. Harlan Krumholz believes the pandemic could be reducing stress for some heart patients, thus reducing heart attacks and strokes.

“After the nation shut down, the air was cleaner, the roads were less trafficked. And so, paradoxically, people say they were experiencing less stress in the pandemic, not more,” said Krumholz, who wrote an April op-ed in The New York Times headlined “While sheltering in place, they were eating healthier, changing lifestyles and bad behaviors,” he said.

At least some medical experts agree.

“The shutdown may have provided a sabbatical for our bad habits,” said Dr. Jeremy Faust, a physician in the division of health policy and public health at Boston’s Brigham and Women’s Hospital. “We’re making so many changes to our lives, and that includes heart patients. If you go to a restaurant three times a week or more, do you realize how much butter you’re eating?”

While some patients may be benefiting from a COVID-19 change of regimen, many people have urgent and undeniable medical needs. And some are pressing through their fear of the virus to seek care, after balancing the risks and benefits.

In March, when the virus took hold, Kate Stuhr-Mack was undergoing a clinical trial at Hoag for her stage 4 ovarian cancer, which had recurred after a nine-month relapse.

Members of her online support group considered staying away from the facility, afraid of contracting the virus. But Stuhr-Mack, 69, a child psychologist, had no choice: To stay in the trial, she had to keep her regular outpatient chemotherapy appointments.

“We all make choices, so you have to be philosophical,” she said. “And I thought it was far more risky not to get my cancer treatment than face the off-chance I’d contract COVID on some elevator.”

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Beginning in March, the COVID-19 pandemic shuttered their popular Gourmet Italia restaurant in Temecula, a wine-growing community of 115,000 southeast of Los Angeles. Dozens of employees were laid off; food stocks quickly became outdated.

They began bleeding cash — about $20,000 every day in lost business, rent and sundry other payments on Gourmet Italia and their other properties, a winery and the pizzeria Spuntino.

While desperate to reopen, the couple also realized the perils involved in serving food to the public with a dangerous pathogen on the loose. The Centers for Disease Control and Prevention’s guidelines were confusing enough for the general public. For restaurants trying to keep loyal patrons safe, the lack of clarity was maddening.

What precisely did social distancing mean inside their restaurant, the Prestifilippos wondered. Did customers expect servers, chefs and busboys to wear masks? How vigilantly did they have to sanitize counters and tables? How often should employees wash their hands?

“It was stressful,” said Charity. “While we understood the government itself was trying to figure all of this out, nobody could give us any hard answers. And we couldn’t devise a plan of attack without permanent information.”

After being advised he could seat his restaurant at only 50% capacity, Alex said, he was later informed there was no capacity limit, as long as tables were spaced 6 feet apart.

“Government health officials were giving owners a moving target. Even restaurant associations were having a hard time getting a handle on the right process,” said Phil Mott, a Colorado-based restaurant consultant. “Owners faced retraining all their employees, but they weren’t even sure what that training entailed.”

The Prestifilippos recently reopened Gourmet Italia and Spuntino, but not without much anguish and deliberation, and many tough decisions.

Beginning in April, Charity joined a weekly virtual meeting with dozens of other restaurant owners in the tightknit tourist community, dotted with privately owned wineries and mom and pop eateries. Many feared they would be forced to close for good if they didn’t reopen soon. Some wanted to “go rogue,” opening collectively and gambling that heath officials would not close them all down.

In the end, the group of Temecula restaurant owners decided to wait, using the time to develop a list of preferred practices for the future, precautions that ranged from providing hand sanitizer and wipes to replacing traditional salt and pepper shakers with disposable packets.

They agreed to document bathroom cleaning schedules and open the parking lot to outdoor tables so customers could keep their distance. Cafes with counter service considered installing plexiglass barriers between diners.

“The idea was to do more than you would probably need — so customers could see that you were doing your best to create a safe place,” said Charity. “But there were also business considerations. Could you be as quick and efficient with your service if you have to take all these precautions? How was all this going to work?”

After emigrating from Sicily, Alex, 51, learned English and opened his first restaurant in 1999. He eventually developed a 7,000-square-foot space with high-end Italian cuisine and white linen tablecloths that as a romantic dining spot.

Charity, 47, was one who found romance there. She came in first as a customer, then met Alex, and they fell in love.

The Prestifilippos received about $300,000 in economic assistance through Small Business Administration loans. Still, it felt as if they were leaking hard-earned money. And the projected costs of implementing all these health precautions — between $500 and $1,000 a day — brought sticker shock.

“I showed Alex the figures and he said, ‘Are you kidding me?’” Charity recalled.

Not only were supply prices escalating with increased demand, but also there were long waits for items such as specialized thermometers that could be applied to the foreheads of employees, and possibly customers, which cost $180 or more — if you could get them. They also needed gallons of sanitizer, masks, gloves and who knew what else?

“I just spent $2,800 on peroxide for the two restaurants and I have no idea how long that’s going to last,” Alex said. Masks cost $1.50 each, and the chefs, servers and busboys use several each shift, he said.

Alex decided not to raise prices to cover the costs. That would not be fair to his customers, he said.

On May 30, after months of quarantine, customers formed a line outside for Gourmet Italia’s first lunch seating.

The diners encountered a coronavirus safety plan that had been months in the making. For starters, the owners kept the front doors open so customers didn’t have to touch the handles and installed hand-sanitizing devices at the entrance.

Servers and busboys wore masks, and the bar and kitchen staff donned gloves as well. Only after tables were seated were plates and wrapped silverware presented. Menus were sanitized after each use, and salt and pepper shakers were brought on demand — and quickly wiped down. Tables were moved into the bar area to create extra distance, and workers patrolled the restaurant to clean surfaces. All 35 workers returned from layoffs.

So far, business has been down. Alex handled 150 diners during the Saturday night of the reopening and brought in $10,000, down from 450 customers and $30,000 on a typical Saturday before the shutdown. Street protests against police violence in Temecula held down the opening-day crowd, he said.

Alex described the opening-night atmosphere as like a family reunion, with people constantly approaching to congratulate him. He had to duck inside his office to get any paperwork done. Alex said he’s sure no customer will get sick in his restaurant. “We have one employee whose only job all day is to sanitize menus, chairs, tables and door handles, and clean the bathroom every half-hour,” he said. “I feel safe.”

And though he hails from an Italian culture of embraces and social kisses, Alex has chosen to put safety over traditional social graces.

“I told myself, ‘I’m not gonna hug,’” he said. “It’s very important to respect the code. I let my employees know — elbow bumps only. No hugs. No hands.”

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The drugs were cheap, and the customers — mostly from Mexico and Central America — did not need prescriptions to buy them. Some of the products featured brand names and colorful packaging that immigrants knew well from their home countries — including Ciprofloxacina, a potent antibiotic, and Dolo Nervi Doce — translated as “Pain Nerve 12” — an injectable B-complex vitamin taken for fatigue.

Many were sheer counterfeits. Others, though legal south of the border, were not approved for sale in the United States. Some had expired. Still others would have been legal if sold by people licensed to do so — but none of the sellers held pharmacist licenses or any other medical credential.

L.A. County authorities seized the drugs last month in an operation that led to the . Their haul included 100,000 foreign-made pills, compounds and injectable medicines they said could have caused serious harm or even death to consumers.

Immigrants, not just from Hispanic countries but from all over the world — and some non-immigrants too — are purchasing a wide array of illegal medications in black markets that are common not only in Southern California but in states such as Arizona, Maryland, Texas, Virginia and Washington, according to law enforcement officials and others familiar with the trade.

“We’re seeing this in all communities across the country that don’t have access to health care services,” said Adolph Falcon, executive vice president of the Washington, D.C.-based National Alliance for Hispanic Health, which provides information and health-related assistance to Hispanic communities nationwide. “These products prey on the desperation of people who can’t afford to see a doctor or go to a legitimate pharmacy.”

The current political climate in the U.S. is also pushing some immigrants to the black market, doctors and researchers say.

“Many patients are afraid they’ll be deported if they come into our clinics, so they buy from the street, said Dr. Anjali Mahoney, the Orange County, Calif., regional medical director for AltaMed Health Services, a large chain of federally funded community clinics whose patients are primarily Latino.

“People are paying for something that doesn’t work and could even harm them, when they could have just as easily come to a clinic and get safe care with a doctor,” Mahoney said.

She added that every one of AltaMed’s 23 clinics in Southern California has reported problems with off-the-street medications. One Latina woman was hospitalized after taking an opiate advertised as blood pressure medicine, she noted.

These dubious products targeted by law enforcement are different from the legitimate prescription pharmaceuticals every year by millions of U.S. residents who cross the border into Canada and Mexico or use licensed online pharmacies abroad to buy their medications at a fraction of the price they would pay in this country.

Although those imports are also technically illegal, from the Food and Drug Administration allow federal agents to take a hands-off approach.

That’s not the case with wares peddled on the streets by often unscrupulous operators.

“Counterfeit medicines may contain the wrong ingredients, contain too little, too much or no active ingredient at all — or contain other, potentially life-threatening hidden ingredients,” said Jeremy Kahn, an FDA spokesman.

Drug companies and pharmacies also have an interest in disrupting the distribution of such medications. The nationwide value of this pharmaceutical black market is difficult to gauge, but it may displace billions of dollars’ worth of legally approved medicine, said Roger Bate, an economist at the American Enterprise Institute and author of the book “Phake: The Deadly World of Falsified and Substandard Medicines.”

Between October 2017 and July 2018, FDA officials confiscated nearly 22,000 packages containing illegal pharmaceuticals from international mail facilities, Kahn said. He said authorities routinely impound various opioids as well as dietary supplements laced with erectile dysfunction drugs and other dubious products. They come from India, China and across Europe — “just about everywhere,” Kahn said.

The medications seized by the FDA are just the tip of the iceberg. The agency estimates it is able inspect sent via international mail that are believed to contain drugs. And many illicit products arrive not through the mail but in suitcases, cars, trucks or cargo ships, authorities say.

The purveyors of these “dodgy medicines” are “myriad and global,” including Chinese and Indian manufacturers, Russian mobsters, Mexican gangs and domestic U.S. groups, said Bate. “There are charlatans and odious actors who don’t mind if their product kills children, adults or breadwinners of entire families.”

Nationwide, many local police departments lack the resources or mandate to investigate sales of illicit pharmaceuticals; otherwise, the number of arrests would probably be much higher, public and industry officials say.

“Not enough attention is paid to this issue,” said Jon Roth, CEO of the California Pharmacists Association. “It’s probably largely operating in the dark shadows of every community. If we put the resources there, we’d see how wide it is.”

L.A. County is one jurisdiction paying attention. In 1999, it formed the Health Authority Law Enforcement Task Force (HALT), after two Latino infants died from taking illegal medications. HALT is the group that made the August arrests.

So far this year, it has arrested 34 people in 54 cases, 48 of them involving illegal pharmaceuticals sold to immigrants, said Erick Aguilar, one of the investigators.

Illegal pharmaceuticals are being sold to immigrants in “every rural swap meet you can find,” and the sellers are becoming more sophisticated, Aguilar said. “They’re better at hiding it,” and “they’re more careful who they sell to.”

In February 2019, three men – two in Southern California and one from Salem, Ore. – to the illegal importation and sale of $11 million worth of pharmaceutical-grade erectile dysfunction drugs falsely marketed across the U.S. as herbal remedies for men. One of the perpetrators imported from China powdered tadalafil, the active ingredient in , and used it to make 5.5 million pills with up to 14 times the level contained in Cialis, according to the FDA.

In 2017 and 2018, the Phoenix police department’s organized-crime commercial unit raided 30 pharmacies in Latino neighborhoods, confiscating “millions of dosages of illegal medicines, some of them outdated by 15 years,” said Detective Sgt. David Lake, who led the unit.

But not all the sellers were members of organized crime. Lake recalled one woman who genuinely believed she was doing something positive for her community by distributing black-market birth control pills.

“She said local girls were having too many babies, and she wanted to help them, but the babies kept being born,” Lake recalled. “When I told her the drugs were counterfeit, she cried for a half-hour straight.”

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Snyder, a Monterey, Calif., mother of two, was a so-called anti-vaxxer for many years, adding her voice to those that rejected mandatory vaccinations for school-age children.

She later realized she was wrong and in 2014 founded a pro-vaccination Facebook group called “Crunchy Front Range Pro-Vaxxers,” which she administers. It is an invitation-only site on which approximately 1,100 members exchange views and information.

Snyder, 38, is also an advocate for pending California legislation, , which targets bogus medical exemptions that allow unvaccinated children to attend school. The number of medical exemptions issued by physicians has in recent years. The Medical Board of California is doctors for issuing questionable exemptions for children.

Meanwhile, some infectious diseases once thought under control are breaking out again because parents failed to have their children vaccinated. Between Jan. 1 and July 25, were reported across 30 states, the most since the disease was in 2000, according to the Centers for Disease Control and Prevention. California has seen 62 new measles cases this year.

We talked to Snyder about her transformation.

As a former opponent of mandatory childhood vaccines, can you describe the mindset?

Anti-vaxxers have been around for a long time, but social media makes it easier to get into a loop. And once you’re there, it’s hard to see outside of it. Algorithms just show you more of what you’re already looking for. If you start searching anti-vaccination stories, that’s what starts popping up on your tagline. You start to think, “Oh, my God, there’s all these people and there’s so much of this going on.” But if you have a chance to peel back from that, you see that it’s actually a very small portion of the population who are really, really loud. The fear makes you angry and it makes you lash out. Once you get into that state, it’s easy to stay there.

Describe a moment when you were in that state of mind.

When my daughter was born, I refused . I remember lying there with my daughter in my arms, and the nurses said, “Hey, we’re going to give her the vitamin K,” and I said, “No, we’re not doing that.” They made me sign a form that said I was going against the recommended medical care. At the time, the anti-vaxxer voices in my head said they were trying to coerce me into doing something dangerous for my child. They told me I was going to have to stay in the hospital longer for observation. I saw that as trying to force me to inject my child with this poison.

What activities did you engage in as an anti-vaxxer?

I joined some social media groups and would get together with some of those mothers who believed what I did. We used to call the pro-vaccination mothers “sheeple.” You’d ask them, “Have you thought about your stance? Have you even done any research?” Because when you’re in that anti-vax mindset, you spend all these hours on the internet, reading studies. I’ve come to realize that a Google search isn’t really research. Most times, you’re not reading an entire study, but only the abstract.

What changed your mind on vaccinations?

In the summer of 2014, I was in one particular anti-vaxxer Facebook group, and there was a debate going on about vaccines, and I started to notice that every time someone disagreed with them, the core members got belligerent, going straight to personal attacks. I also noticed that every single point they brought up had this immense conspiracy to go along with it. By that point, I’d started to think, “Do I really believe in all these conspiracies? Am I really that afraid, or can I go back and look at the evidence again?” By then, my daughter was 8 months old, and I just got over the fear I had as a first-time mom. I realized that my daughter was going to be OK.

How do you think the vaccination fight will play out in California and nationally?

I think California is setting a precedent for vaccine laws across the country. We’re making sure that medical exemptions for vaccines are not being bought, and that’s a very serious problem. Other states have seen the work we’ve done and they’re working on their own legislation. We’ve come to realize that unless we get more vocal about our pro-vaccine stance, the anti-vaccine voices just get louder and louder. I sometimes refer to anti-vaxxers as the drunk drivers of public health. They’re dangerous.

What do you say today to the anti-vaxxers you once aligned with?

I tell people that I understand their fears. I understand that parenting is very difficult, and all of us truly want the best for our children. I also know that the evidence is out there when people are willing to let their guards down. And I’m always happy to share real solid scientific evidence with people who want to do their critical thinking for themselves. I’m hoping people come around. I did. But we can’t force anybody. We just want to protect everyone else.

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FRESNO, Calif. — On the 15-mile drive between his two Central Valley medical clinics, Dr. J. Luis Bautista often passes armies of farmworkers stooped over in the fields, picking onions, melons and tomatoes.

Most of the 30,000 annual office visits to his small staff of doctors and nurses in downtown Fresno and the nearby rural town of Sanger are by these farmworkers. Many of them are undocumented.

The 64-year-old physician has personal insight into the struggles of these laborers: He was once one of them. As a boy, he picked fruit alongside his parents and nine siblings in Ventura County. The family made $4,000 a year back then, a little over $30,000 in today’s dollars — rarely enough to spare for doctor’s visits.

These days, Bautista sees that many farmworkers still lack the transportation, money or time off from work to treat injuries, let alone seek preventive medical care. Plus, there is the heightened fear that by seeking medical treatment they might be exposed to federal immigration authorities.

“I pledged in medical school to help these people in the farm fields,” said Bautista. “I knew how it felt not to have anything, not to have the money to go to a doctor.”

Now he treats them whether or not they have money — or legal documents. “We never say no to patients,” he said.

President Donald Trump’s campaign pledge to immigrants who have entered the U.S. illegally has fostered fear among farmworkers nationwide. Terrified they’ll be caught in an immigration dragnet, farm laborers across the San Joaquin Valley without U.S. citizenship or official documents avoid driving to see a doctor or visit an emergency room.

Although California the state’s cooperation with U.S. immigration enforcement, some jurisdictions outside the Central Valley have decided to participate in federal efforts to detain undocumented workers. Many here fear that local officials will soon join them, Bautista said.

Farmworkers also worry that personal information housed in doctors’ offices could find its way into the hands of federal authorities. And some fear that if they enroll in programs for low-income residents, they’ll later be denied permanent residence, the so-called green card, or U.S. citizenship.

The Trump administration has proposed a federal rule change that would make it harder for legal immigrants to get green cards if they have received certain public assistance benefits, including food stamps, housing subsidies and Medicaid — the government-funded health care program for people with low incomes.

“Many people don’t know what the government will do,” Bautista said. “They tell me that one reason they don’t go to the doctor is over fear they’ll be reported.”

Bautista’s two clinics provide a haven for immigrants burdened by these concerns. Patients are never asked about their immigration status, and the staffs have set up protocols in case the offices are raided by immigration authorities.

“I feel secure with him,” said Julia Rojas, a 45-year-old undocumented mother of five who has picked oranges in Fresno County for two decades. “He’s one of us.”

Bautista accepts as payment whatever his patients can offer: onions, handmade key chains, eggs, even live chickens.

Dan Baradat, a Fresno personal injury lawyer who has handled cases involving migrant workers, said Bautista’s clinics are indispensable to the Central Valley’s poorer residents. “They’re stand-up people who provide care to people who could not otherwise afford it,” he said.

Bautista’s clinics are among a network of federally supported community clinics that provide care for nearly 1 million migratory and seasonal agricultural workers and their families around the U.S. But few providers have a better connection to the community they serve than Bautista, who in 2013 founded a nonprofit that raises money to assist low-income farm families with food and clothing, and provides scholarships to send their children to college.

Born in Fresno, Bautista was deported with his parents when he was just 3 months old. He lived in Mazatlán, Mexico, until he returned to the U.S. at age 12.

In 1979, at age 24, he was picking lemons when his mother came running out to the fields with the letter announcing he’d been admitted to medical school. She’d always been big on education for her 10 children.

Bautista attended the in Milwaukee and did his residency in internal medicine at the University of Nevada-Reno.

Today, two of Bautista’s four sons are also doctors. A third son, whom he adopted, is a physician assistant, as is his son-in-law, who was a farmworker before joining the clinic. His fourth son is the clinic manager. All of them know that fear of deportation is affecting farmworkers’ health.

Dr. Ed Zuroweste, founding medical director of the nationwide Migrant Clinicians Network, said a recent survey of providers within the organization underlined these fears.

“What we’re seeing on the front lines is that farmworkers and their families are not coming in for regular appointments as frequently as they had before,” he said.

Bautista said many undocumented farmworkers rely on home remedies to treat ailments such as diabetes and high blood pressure, often until it’s too late for effective medical treatment. “By the time I see many diabetic patients, their feet are already necrotic and we have to amputate,” Bautista said. “It’s terrible to see.”

Jose Jimenez, a former farmworker, said his father, who is not in this country legally, was too afraid to drive to Bautista’s office, even after developing signs of melanoma on his face. His dad’s fears were heightened last year following the , the parents of six children, whose van overturned while they were fleeing federal immigration officers in nearby Delano.

“He was even afraid to drive to the supermarket,” said Jimenez, 30. “He knew that if he was picked up, he’d be deported. For a close-knit family like ours, that would mean losing everything.” But Jimenez finally persuaded his father to visit Bautista.

Bautista’s clinics are on guard against U.S. immigration officials, known in this community as la migra.

Law enforcement officials requesting records are asked for a warrant, and staff members are on the lookout for intruders. “By the time any ICE officers got inside the office,” Bautista said, “we’d have people hiding in the restrooms.”

Julia Rojas said her fears of deportation almost killed her. Years ago, before she began seeing Bautista, she chose to ignore the piercing pain in her lower abdomen. In the U.S. without papers and afraid to drive, she spent nearly a day drinking mint leaves in hot water — a remedy her mother used for stomach pain back in Mexico.

Unable to stand the spasms, she finally went to the nearest emergency room, where doctors removed her gall bladder. “Among undocumented workers in the fields, we have a dark little joke,” Rojas said. “You can survive out here. Just don’t get sick.”

This <a target="_blank" href="/public-health/a-medical-sanctuary-for-migrant-farmworkers/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">